(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "The American journal of the medical sciences"

X, 



Property of the 

Lancaster City and County 
Medical Society 



No 



THE 



AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 



EDITED BY 



ISAAC HAYS, M.D., 

SURGEON TO WILLS* HOSPITAL. 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION J OF THE AMERICAN PHILOSOPHICAL SOCIETY J OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, 
&C. &C. &C. 



NEW SERIES. 
YOL. XXIY. 



4 




PHILADELPHIA: 
BLAN, CHARD & LEA. 

1852, 



69450 



Entered according to Act of Congress, in the year 1852, by 
BLAN CHARD AND LEA, 
in the Cleric's Office of the District Court of the Eastern District of Pennsylvania. 




PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



TO READERS AND CORRESPONDENTS. 

A number of communications have been received, which shall receive early 
attention. 

Correspondents who desire their papers to appear as original articles in this 
Journal should send them to us exclusively. We must repeat what we have said 
on a former occasion, that the simultaneous communication of the same article 
to several journals, savours of the spirit of advertising, and gives rise to the 
suspicion that the aim of the author is rather to spread his own fame than to 
advance our science. We regret to have to repeat these remarks, but it has 
been rendered necessary by the breach of confidence and good faith of which 
one of our correspondents has been guilty, in sending his communication, after 
it had been printed off for the present number of this Journal, to a monthly 
journal, in the June number of which it has appeared. 

We must request our correspondents to write their names distinctly. From 
a neglect of this, in our last number, page 565, the name of Henry A. Birrell, 
of Clinton, N. C, was printed H. A. Bizzen. 

The following works have been received: — 

Sketches of Brazil; including New Views on Tropical and European Fever, 
with Remarks on a Premature Decay of the System Incident to Europeans on 
their return from Hot Climates. By Robert Dundas, M. D., for twenty-three 
years Medical Superintendent of the British Hospital, Bahia, &c, &c. London, 
1852. (From the Author.) 

On the Fallacies of Homoeopathy, and the Imperfect Statistical Inquiries on 
which "the Results of that Practice are estimated. By C. H. F. Routh, M. D., 
M. R. C. S„ &c, &c, &c. London, 1852. (From the Author.) 

Statistical Report of the Epidemic Cholera in Jamaica. By John Parkin, 
M.D. London, 1852. (From the Author.) 

Resume de Plusieurs Memoires de Physiologie Experimental, lus ou pre- 
senters a FAcademie des Sciences dans Fannee 1847. Par M. E. Brown-Se- 
quard, D. M. P. (From Dr. Brown-Sequard.) 

Cases of Amputation : 1st. Below the Knee, subsequently to the removal of 
the Foot at the Tibio-Tarsal Articulation ; and 2d, at the Shoulder during spread- 
ing gangrene, consequent on Disease of the Elbow- Joint; the application of a 
new saw in both. With Observations. By Richard G. H. Butcher, F. R. C. S. I., 
&c. Dublin, 1851. (From the Author.) 

On the Treatment of Fractures in the vicinity of the Ankle-Joint ; with Obser- 
vations on the Practice of Tenotomy as facilitating Reduction of the Broken 
Bones. By Richard G. H. Butcher, F. R. C. S. I., &c. Dublin, 1852. (From 
the Author.) 

The Principles of Surgery. By James Miller, F. R. S. E., F. R. C. S. E., &c. 
Third American, from the second and enlarged Edinburgh Edition. Illustrated 
by two hundred and forty engravings on wood. Revised, with additions, by 
F. W. Sargent, M.D., Member of the College of Physicians of Philadelphia, 
Author of "Minor Surgery," etc. Philadelphia: Blanchard & Lea, 1852. 
(From the Publishers.) 

The Diseases of the Skin. By Erasmus Wilson, F. R. S., Consulting Surgeon 
to the St. Pancras Infirmary. Third American, from the third London Edition. 
Philadelphia: Blanchard & Lea, 1852. (From the Publishers.) 

Lectures on the Principles and Practice of Surgery. By Bransby B. Cooper, 
F. R. S., Senior Surgeon to Guy's Hospital, &c. Philadelphia : Blanchard & 
Lea, 1852. (From the Publishers.) 

The History, Diagnosis, and Treatment of the Fevers of the United States. 
By Elisha Bartlett, M. D., Professor of Materia Medica and Medical Juris- 
prudence in the College of Physicians and Surgeons of the University of the 



4 



TO READERS AND CORRESPONDENTS. 



State of New York, &c. Third edition revised. Philadelphia : Blanchard & 
Lea, 1852. (From the Publishers.) 

A Treatise on the Practice of Medicine. By George B. Wood, M. D., Pro- 
fessor of Theory and Practice of Medicine in the University of Pennsylvania, 
President of the College of Physicians of Philadelphia, fee, &c. Third edition, 
vols. ii. Philadelphia: Lippincott, Grambo & Co., 1852. (From the Author.) 

Elements of Chemistry ; including the Applications of the Science in the 
Arts. By Thomas Graham, F. R. S., Professor of Chemistry in the University 
College, London, &c, &c. Second American from an entirely revised and 
greatly enlarged English Edition. With numerous wood engravings. Edited 
with Notes. By Robert Bridges, M.D., Professor of Chemistry in Philadel- 
phia College of Pharmacy, &c, &c. Philadelphia : Blanchard & Lea, 1852. 
(From the Publishers.) 

An Analysis of Physiology; being a Condensed View of its most important 
Facts and Doctrines. Designed especially for the Use of Students. By John 
J. Reese, M.D., Lecturer on Materia Medica, &c, &c. Second edition revised 
and enlarged. Philadelphia: Lindsay & Blakiston, 1852. (From the Pub- 
lishers.) 

Du Rachitis, de la Fragilite des Os, de TOsteomalacie. Par E. J. Betlard 
(de Philadelphie), D. M. P., fee, &c. Paris, 1852. (From the Author.) 

Facultie de Medecine de Paris. These pour le Doctorat en Medecine pre- 
sentee et soutenue le 2 Fevrier, 1852. Par A. A. Verneuil, de Paris. Recher- 
ches sur la locomotion du coer. Paris, 1852. (From Dr. Brown-Sequard.) 

These pour le Doctorat in Medecine. Par M. J. Benjamin Coste. Recher- 
ches Experimentales et Observations Cliniques sur le role de l'Encephale, et 
particulierement de la protuberance annulaire, dans la respiration. Paris, 1851. 
(From Dr. Brown-Sequard.) 

These pour le Doctorat en Medecine. Par F. W. Bonneein. R6cherches 
Experimentales sur Taction convulsivente des principaux poisons. Paris, 1851. 
(From Dr. Brown-Sequard.) 

Twenty-third Annual Report of the Inspectors of the Eastern State Peniten- 
tiary of Pennsylvania. Transmitted to the Senate and House of Representatives, 
Feb., 1852. Philadelphia, 1852. (From Dr. R. A. Given.) 

Ninth Annual Report of the Managers of the State Lunatic Hospital of the 
State of New York. Transmitted to the Legislature, Feb., 1852. Albany, 1852. 

Third Annual Report of the Managers of the St. Joseph's Hospital, March, 
19, 1852. Philadelphia, 1852. (From Dr. W. E. Horner.) 

Thirty-fifth Annual Report of the state of the Asylum for the Relief of Per- 
sons deprived of the use of their Reason. 

First Annual Report of the Trustees of the New York State Asylum for 
Idiots. 

Sixty-fifth Annual Report of the Regents of the University of the State of 
New York. Made to the Legislature of the State of New York, March 1, 1852. 
Albany, 1852. (From Dr. T. R. Beck.) 

Report of the Eastern Lunatic Asylum, in the city of Williamsburg, Va., 
1851. Richmond, 1852. (From Dr. J. M. Gait.) 

The Annual Discourse before the Philadelphia County Medical Society, de- 
livered Feb. 10, 1852. By the President, Samuel Jackson, M.D., formerly of 
Northumberland. Published by the Society. Philadelphia, 1852. 

The Organizing of the American Medical Association, read before the Phila- 
delphia County Medical Society, Feb., 1852. By the President, Samuel J ackson, 
M. D., formerly of Northumberland. Philadelphia, 1852. 

A Memorial to the Legislature of the State of Louisiana, for the Registration 
of Births, Marriages, and Deaths. Respectfully submitted, by J. C. Simonds, 
M.D., on behalf of the Louisiana State Medical Society, and the Physico-Medical 
Society of New Orleans. 

An Introductory Lecture delivered at the opening of the 32d Session of the 
Medical College of Ohio, October 15, 1851. By R. D. Mussey, M. D., Professor 
of Surgery. Cincinnati, 1851. (From the Author.) 

Valedictory Address to the Graduates of the Philadelphia College of Phar- 
macy, delivered in Sansom Street Hall, March 18, 1852. By Wm. Proctor, Jr. 
Published by the Class. Philadelphia, 1852. (From the Author.) 



TO READERS AND CORRESPONDENTS. 



5 



An Address to the Graduates of the Medical Department of the St. Louis 
University. Session 1851-52. By Charles A. Pope, M. D., Professor of Sur- 
gery. St. Louis, 1852. 

Valedictory Address to the Graduating Class of the Medical College of the 
State of South Carolina. Delivered by appointment of the Faculty, at the 
Public Commencement, held in St. Andrew's Hall, on the 12th of March, 1852. 
By E. Geddings, M. D., Professor of Surgery. Charleston, 1852. 

Lecture, Introductory to the Courses of the Eleventh Session of the Phila- 
delphia College of Medicine. Delivered March 8, 1852. By Rush Van Dyke, 
M.D., Professor of Materia Medica and General Therapeutics. Published by 
the Class. Philadelphia, 1852. 

The Vital Statistics and Sanitary Condition of Memphis, Tennessee. An 
Anniversary Address. Delivered, by appointment, before the Memphis Medi- 
cal Society. By George R. Grant, M. D. New Orleans, 1852. (From the 
Author.) 

On the Sanitary Condition of Memphis, Tennessee; being a Reply to Dr. 
Grant. By G. A. Smith, M. D., Surgeon to the Memphis Charity Hospital. 
Reprinted from the New Orleans Medical and SurgicalJournal. New Orleans, 
1852. 

Constitution of the American Medical Society in Paris. Instituted Novem- 
ber 15, 1851. Paris, 1852. 

Medical Commencement of the University of Pennsylvania; held on Satur- 
day, April 3, 1852 ; with a Valedictory. By Samuel Jackson, M. D., Professor 
of 'the Institutes of Medicine. Philadelphia, 1852. (From Dr. Horner.) 

Catalogue of the Trustees, Faculty, and Students of the Medical College of 
the State of South Carolina. Session of 1851-52. Charleston, 1852. 

Second Annual Announcement of the Medical Department of the University 
of Nashville. Nashville, 1852. 

The following Journals have been received in exchange : — 

Vierteljahrschrift fur die praktische Heilkunde herausgegeben von der medi- 
cinischen Facultal in Prag. Red. Dr. J. Halla und Dr. J. V. Hasner, VIII. 
and IX. Jahrgang, 1852. 

Gazette Medicale de Paris, Nos. 7, 8, 9, 10, 11. 1852. 

Journal des Connaissances Medico-Chirurgicales. Publie par le Dr. A. 
Martin-Lauzer. March, 1852. 

Monthly Journal of Medical Science. Edited by Professors Christison, 
Syme, Simpson, Bennett, and Drs. Maclagan and Robertson. March, April, 
June, 1852. 

Medica] Times and Gazette. March, April, May, 1852. 

The British and Foreign Medico-Chirurgical Review. April, 1852. 

London Journal of Medicine. April, May, June, 1852. 

The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, M. D. April, 1852. 

Dublin Medical Press. March, April, May, 1852. 
^The Dublin Quarterly Journal of Medical Science. May, 1852. 

Provincial Medical and Surgical Journal. Joint-Editors, W. H. Ranking, 
M. D., and J. H. Walsh, Esq. March, April, May, 1852. 

Canada Medical Journal. Edited by R. L. McDonnell, M. D., and A. M. 
David, M. D. March, April, May, 1852. 

The Charleston Medical Journal and Review. Edited and Published by D. 
J. Cain, M. D., and P. Peyre Porcher, M. D. March, May, 1852. 

The American Journal of Insanity. Published by the New York State Lu- 
natic Asylum. Utica: April, 1852. 

The American Journal of Pharmacy. Published by authority of the Phila- 
delphia College of Pharmacy. Edited by Wm. Proctor, Jr., Professor of Phar- 
macy, &c. &c. April, 1852. 

The New Jersey Medical Reporter, and Transactions of the New Jersey Me- 
dical Society. Edited by Isaac Parrish, M. D. April, May, June, 1852. 

The Stethoscope and Virginia Medical Gazette. Edited by P. Claiborne 
Gooch, M. D. April, May, June, 1852. 

1* 



6 



TO READERS AND CORRESPONDENTS. 



The Western Journal of Medicine and Surgery. Edited by L. P. Yandell, 
M. D., and T. S. Bell, M. D. May, June, 1852. 

The New York Journal of Medicine. Edited by S. S. Purple, M. D. May, 
1852. 

The North Western Medical and Surgical Journal. Edited by W. B. Her- 
rick, M. D., and H. A., Johnson, M. D. May, 1852. 

The Western Lancet. Edited by L. M. Lawson, M. D., and Geo. Menden- 
hall, M. D. April, May, June, 1852. 

The Ohio Medical and Surgical Journal. Edited by Richard L. Howard, 
M.D. May, 1851. 

The New Orleans Monthly Register. Edited by A. Foster Axson, M. D. 
April, May, June, 1852. > 

The Transylvania Medical Journal. Edited by E. L. Dudley, M. D. April, 
May, June, 1852. 

The New York Medical Gazette and Journal of Health. Edited by D. M. 
Reese, M. D. April, May, June, 1852. 

The Boston Medical and Surgical Journal. Edited by J. C. V. Smith, M. D. 
April, May, June, 1852. 

The Medical Examiner. Edited by F. G. Smith, M. D., and John B. Biddle, 
M. D. April, May, June, 1852. 

The North Western Medical and Surgical Journal. Edited by John Eyans, 
M.D. March, 1852.^ 

The New Hampshire Journal of Medicine. Edited by Edward H. Parker, 
M. D. April, May, June, 1852. 

The New York Journal of Pharmacy. Published by Authority of the Col- 
lege of Pharmacy of the City of New York. Edited by B. W. McCready, M. D., 
Professor of Mat. Med. and Pharm. January, February, March, 1852. 

The Opal, devoted to Usefulness. Edited by the Patients of the State Lu- 
natic Asylum. Utica : New York. April, May, June, 1852. 

The American Journal of Dental Science. Edited by Chapin A. Harris, 
M. D., D. D. S., and A. A. Blandy, M. D., D. D. S. January, 1852. 

Buffalo Medical Journal. Edited by Austin Flint, M. D. April, May, 
June, 1852. 

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling, 
M. D. April, May, June, 1852. 

The American Journal of Science and the Arts. Edited by Professor B. 
Silliman, B. Silliman, Jr., and James D. Dana; and in the Departments of 
Chemistry and Physics. By Dr. Wolcott Gibbs, May, 1852. 

The East Tennessee Record of Medicine and Surgery. Edited by Frank A. 
Ramsay. April, 1852. 

L'Union Medicale de la Louisiane, Revue Mensuelle. Editeurs — Redacteurs 
Charles Delery, D. M. P., et Edward Martin, D. M. P. Nos. 3, 4, 5, 1852. 



Communications intended for publication, and Books for Review, should be sent,/ree 
of expense, directed to Isaac Hats, M.D., Editor of the American Journal of the Medical 
Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as above, and 
sent (carriage paid) under cover, to John Miller, Henrietta Street, Covent Garden, London; 
or to John Wiley, or G. P. Putnam, New York ; or W. D. Ticknor, Boston; or M. Hector 
Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us safely and without delay. We 
particularly request the attention of our foreign correspondents to the above, as we are 
often subjected to unnecessary expense for postage and carriage. 

All remittances of money, and letters on the business of the Journal, should be addressed 
exclusively to the publishers, Messrs. Blanchard & Lea. 

0^/* The advertisement-sheet belongs to the business department of the Journal, and 
all communications for it should be made to the publishers. 



CONTENTS 



OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. XLVII. NEW SEMES. 
JULY, 1852. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Medical and Surgical Notes of Campaigns in the War with Mexico, 
during the years 1845, 1846, 1847, and 1848. By John B. Porter, M. P., 
Surgeon U. S. Army. - - - - - - -13 

II. Contributions to Aural Surgery. — Analysis of One Hundred and Forty 
Cases of Diseases of the Ear. By Edward H. Clarke, M. D., Boston, 
Mass. .------..31 

III. Report of Twenty-five Cases of Urinary Calculus, in Twenty-three of 
which the Bi-lateral Operation was performed. By Paul F. Eve, M. D., 
Professor of Surgery in the Nashville University, Tennessee. - - 41 

IV. On the Climate and Diseases of California. By James Blake, M. D., 
F.R.S. - - - - - - - - 53 

V. A Case of Saccharine Diabetes, with Tabular Observations of its Patho- 
logy, and the Results of Treatment. By Charles Frick, M.D., Baltimore. 64 

VI. Extracts from the Records of the Boston Society for Medical Improve- 
ment. By Wm. W. Morland, M. D., Secretary. - - - - 78 

VII. Report on the Action of Cochituate Water on Leaden Pipes, and the 
Influence of the same on Health. By Jacob Bigelow, M. D., Professor 

Ojf Materia Medica and Clinical Medicine in Harvard University - 98 

VIII. On the Employment of the Chloride of Sodium in the Treatment of 
Intermittent Fever. By W. P. Lattimore, M. D. - - - - 101 

IX. New Views concerning the Nature and Cause of Tubercular Deposits. 

By Matthew Troy, M. D., of Whiteville, North Carolina. - - 104 

X. Phosphate of Lime in Phthisis. By S. Kneeland, Jr., M. D. Read 
before the Boston Society for Medical Improvement, April 26, 1852. - 117 

XI. Observations on the Generation of Uric Acid, and its Crystalline Forms. 

- By S. Weir Mitchell, M. D. [With five wood-cuts.] - - - 121 

XII. Report of Cases of Operative Midwifery, with the particulars of a 
novel operation. By Augustus K. Gardner, M. D., Fellow of the Mass. 
Medical Society, N. Y. Academy of Medicine, District Physician of the 

N. Y. Lying-in Asylum, &c. &c. ------ 125 

XIII. Case of Resection of the Superior Maxillary and Malar Bones. By 
Daniel Brainard, M. D., Prof, of Surgery, etc. - 131 



8 



CONTENTS. 



REVIEWS. 

ART. PAGE 

XIV. The Principles of Surgery. By James Miller, F.R.S.E., F.R.C.S.E., 
&c. &c. Third American from the second and enlarged Edinburgh edi- 
tion, illustrated by two hundred and forty engravings on wood. Revised, 
with additions, by F. W. Sargent, M. D., member of the College of 
Physicians of Philadelphia, &c. Philadelphia, Blanchard & Lea, 1852: 
8vo. pp. 751. - - - - - - -133 

XV. Report of the Births, Marriages, and Deaths of Massachusetts, for the 
year 1850. 

Eight Reports of the Births, Marriages, and Deaths of Massachusetts, for 
the eight years and eight months, from May 1, 1841, to December 31, 
1849. 

Two Reports of the Births, Marriages, and Deaths of the State of New 

York, for the years 1847 and 1848. 
A Memorial to the Legislature of Louisiana, for the Registration of Births, 

Marriages, and Deaths, on behalf of the Louisiana State Medical Society. 

By J. C. Simonds, M. D. 147 



BIBLIOGRAPHICAL NOTICES. 

XVI. A Treatise on the Diseases of the Chest i being a Course of Lectures 
delivered at the New York Hospital. By John A. Swett, M. D. New 
York, 1852: 8vo. pp. 595. 165 

XVII. Renorts of American Institutions for the Insane. 

1. Of the New York State Lunatic Asylum, for 1849 and 1850. 

2. Of the New York City Asylum (BlackwelFs Island), for 1849 and 1850. 

3. Of the New Jersey State Asylum, for 1849 and 1850. 

4. Of the Pennsylvania Hospital for the Insane, for 1849 and 1850. 

5. Of the Frankford Asylum, for 1848, 1849, and 1850. 

6. Of the Maryland Hospital, for 1846, 1847, 1848, 1849, and 1850. - 174 

XVIII. Obstetrics : The Science and the Art. By Charles D. Meigs, 
M. D., Professor of Midwifery, and the Diseases of Women and Children, 
in Jefferson Medical College, at Philadelphia, etc. etc. Second edition, 
revised. With one hundred and thirty-one illustrations. Philadelphia, 
Blanchard & Lea, 1852 : 8vo. pp. 759. - - - - - 189 

XIX. The History, Diagnosis, and Treatment of the Fevers of the United 
States. By Elisha Bartlett, M. D., Professor of Materia Medica and 
Medical Jurisprudence in the College of Physicians and Surgeons of the 
University of the State of New York, etc. etc. Third edition, revised. 
Philadelphia, Blanchard & Lea, 1852: 8vo. pp. 595. - - - 190 

XX. Homoeopathy: An . Examination of its Doctrines and Evidences. 
[Fiske Fund Prize Dissertation.] By Worthington Hooker, M. D. New 
York, 1851: 12mo. pp. 146. 

On the Fallacies of Homoeopathy, and the Imperfect Statistical Inquiries 
on which the Results of that Practice are estimated. By C. H. F. Routh, 
M. D., M.R.C. S. London, 1852: 8vo. pp. 85. - - - -191 

XXI. Lectures on the Principles and Practice of Surgery. By Bran shy B. 
Cooper, F. R. S., Senior Surgeon to Guy's Hospital, &c. Philadelphia, 
Blanchard & Lea, 1852: 8vo. pp. 771. 194 

XXII. An Essay on Organic or Life Force. By J. H. Watters, A. B. 
Philadelphia, Lippincott, Grambo & Co., 1851: 8vo. pp. 36. - - 197 

XXIII. On Syphilis, Constitutional and Hereditary ; and on Syphilitic 
Eruptions. By Erasmus Wilson, F. R. S. London, 1852 : 8vo. pp. 235. 205 



CONTENTS. 



9 



ART. PAGE 

XXIY. Uber secondare Erkrankung einzelner Riickensmarksstr'ange und 
ihrer Fortsetzungen zum Gehirne. 

A Consideration of the Secondary Degeneration of Particular Fasciculi of 
the Spinal Cord, and their Continuation to the Brain. — Transactions of 
the Imperial Academy of Sciences, Vienna, Vol. VI. part 3, 1851. - 210 

XXV. Elements of Chemistry ; including the Applications of the Science 
in the Arts. — By Thomas Graham, F. R. S., Professor of Chemistry in 
University College, London ; Vice-President of the Chemical Society, &c. 
&c. Second American from an entirely revised and greatly enlarged 
English edition, with numerous wood engravings. Edited, with notes, 
by Robert Bridges, M. D., Professor of Chemistry in the Philadelphia 
College of Pharmacy, &c. Philadelphia, Blanchard & Lea, 1852: 8vo. 213 

XXVI. Review of Materia Medica, for the Use of Students. By John B. 
Biddle, M. D., etc. etc. With illustrations. Philadelphia, Lindsay & 
Blakiston, 1852 : 12mo. pp. 322. 214 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 

FOREIGN INTELLIGENCE. 



Anatomy and Physiology. 



1. On the Molecular Origin of the 
Tissues. By Dr. Bennett. 

2. Pathological Cell-Development. 
By Dr. Gairdner. 

3. Structure of Arteries. By Mr. 
Drummond. - 

4. Development of Pus-Corpuscles. 
*By Dr. Sanders. - 

5. Fibrin in the Blood of the 
Foetus. By Dr. Drummond. 

6. Influence of Muscular Paralysis 
on the Modification of the Blood, 



215 



216 



- 217 
217 



218 



PAGE 

and on the Duration of Irrita- 
bility. By M. Brown-Sequard. 218 
Mode of Termination of the 
Nerves in the Skin of the Fin- 
gers. By Dr. Rudolph Wagner. 218 
On the Function of the Spleen 
and other Lymphatic Glands as 
Secretors of Blood. By Prof. J. 
H. Bennett, M. D. - 
Influence of Medicines on the 
Temperature of the Body. By 
MM. Dumaril, Demarquay, and 
Lecomte. ----- 



218 



219 



Organic Chemistry. 



10. Constituents of the Splenic 
Fluid. By Scherer. - 



11. Composition of the Succus En- 
tericus. By Zander. 



- 219 | tericus. Bv Zander. - - 220 
Medical Pathology and Therapeutics and Practical Medicine. 



12. Treatment of Albuminuria. 

By Dr. C. Handfield Jones. - 220 

13. Treatment of Intermittent Fe- 
ver by Quinine in large doses. 

By Dr. Meyer, of Berlin. - - 221 



14. Iodine Clysters in the Treat- 
ment of Dysentery. By Dr. 
Eimer. ----- 222 

15. Starch in Cutaneous Diseases. 

By M. Cazenave. - - - 223 



10 



CONTENTS. 



PAGE 

16. Solution of Nitrate of Silver in 
Pruritus of the Genital Organs. 

By Winternitz. - - - < - 223 

17. Cauterization of the Glottis in 
Hooping -Cough. By M. Jou- 
bert. - - - 223 

18. On the Hemorrhagic Diathesis. 

By Dr. Lange. - - - - 223 

19. Spontaneous Development of 
Gas in the Blood as a Cause of 



Sudden Death. By M. Durand 
Fardel. 224 

20. Infantile Phlebitis, with Puru- 
lent Deposits, Erysipelas, and 
Jaundice, arising from Inflam- 
mation of the Umbilical Vein. 

By Dr. W. B. Herapath. - - 225 

21. Vaccination tested by the Ex- 
perience of half a Century. By 
Dr. George Gregory. - - 228 



Surgical Pathology and Therapeutics, and Operative Surgery. 



22. Curative Treatment of Aneu- 
rism of the Aorta. By Dr. O'B. 
Bellingham. - - - - 235 

23. Popliteal Aneurism cured by 
Compression. By T. Stephens, 
Esq. - - " . " . ■ " 23 ? 

24. Account of the Dissection of a 
Subject in whom two Popliteal 
Aneurisms had been treated by 
Compression four years previous- 
ly ; with some Remarks, and a 
Table of the Cases in which Com- 
pression has been successfully 
employed. By O'B. Bellingham, 

M. D. - - - - - 237 

25. Deligation of the External Iliac 
Artery. By John Harris, Esq. 243 

26. Operations for Retention of 
Urine, occasioned by inveterate 
Stricture. By John Simon, Esq. 243 

27. On the Use of Chloroform in 
the Treatment of Stricture of the 
Urethra with Retention of Urine. 

By R. J. Mackenzie, Esq. - 250 

28. New Mode of operating for 



Ovarian Dropsy. By Dr. I. B. 
Brown. 252 

29. Gradual Reduction of Hernias 
long Irreducible. By M. Mal- 
gaigne. ----- 953 

30. Circular Arterial Distribution 
around the Neck of a direct In- 
guinal Hernia. By Prof. Riz- 
zoli. 253 

31. Tracheotomy in Croup. By 

M. Trousseau. - - - - 253 

32. Autoplastic Treatment of Ra- 
nula. By M. Forget. - - 254 

33. On Opening Buboes by Mul- 
tiple Punctures. By M. Videl. 255 

34. On Ununited Fracture. By 
_Prof. Syme. - - - - 256 

35. Treatment of Ununited Frac- 
ture by the Application of Tinc- 
ture of Iodine. By Prof. Blasius. 257 

36. Dislocation of the Clavicle 
backwards. By M. Foucard - 258 

37. Foreign Bodies in the Air- 
Passages. By M. Jobert. - 258 

38. Statistics of Operations for 

I Cancer. By Mr. Paget. - - 259 



Midwifery. 



39. Chlorosis of Pregnancy. By 

M. Cazeaux. - - - - 260 

40. Two Cases of Females who had 
attained the age of forty-eight 
years without having men- 
struated. By Dr. Henry Oldham. 261 

41. Successful Case of Parturition 
in a Patient who had previously 
undergone Ovariotomy by a large 
Incision. By John Crouch, Esq. 262 

42. Rupture of the Vagina, with 
Passage of the Foetus into the 
Cavity of the Abdomen. By M. 
Danyau. - - - - 262 



43. A Stethosopic Indication of 
the Separation of the Placenta. 

By M. Caillant. - - - 263 

44. Hemorrhage from Inversion of 
the Uterus, in which the opera- 
tion of Transfusion was success- 
fully performed : with remarks 
on the employment of Transfu- 
sion generally. ByJohnSoden, 
Esq. 264 

45. Sudden Death after Parturi- 
tion. By Dr. Keith. - - 266 

46. Sudden Death following De- 
livery. By M. Robert. - - 268 



CONTENTS. 



11 



Medical Jurisprudence and Toxicology. 



page 

47. Peach-Leaf "Water. By Messrs. 
Fellenberg and Konig. - - 268 

48. Detection of Mercury in the 
Body of a Person dying of Mer- 
curial Cachexy. By M. Gorup- 
Besanez. 269 

49. On Poisoning by Datura, in 
Bombay. By Dr. Giraud. _ - 269 

50. Question of Pregnancy in 
Bodies far gone in Putrefaction. 

By Dr. Casper. - - - 269 

51. Eaters of Arsenic. - - - 270 

52. Elimination of certain Poi- 
sons. Comparison of the Re- 
sults. Action of Ethylamine and 
of Amylamine on the Animal 
Economy. By M. Orfila - - 270 

53. Dyson v. Dyson. - - - 271 

54. Suicide or Homicide. - - 271 



[ 55. New Test of Mercury. - 
I 56. Morphine and Chloroform. 

57. Smothering voluntarily Pro- 
duced. .... 

58. Case of Poisoning by Atropin. 
By Dr. James Andrew. 

59. Bite of the Yiper in France. - 
| 60. On the Hydrated Peroxide of 

Iron and Magnesia as Antidotes 

in Poisoning with Arsenic. By 

J. Haidlen. - 
61. Magnesia as an Antidote to the 

Salts of Copper. By M. Roucha. 
| 62. Impotence. By Mr. Hunt. - 

63. Blood Stains. - 

64. Early Viability. By M. Yel- 
peau. - 

65. Fractures of the Foetal Cra- 
nium without External Violence. 



page 
271 
272 



- 272 

273 
274 



274 

275 
275 
275 

- 276 



276 



AMERICAN INTELLIGENCE. 
Original Communications. 



On Belladonna as a Prophylactic 

in Scarlatina. By George L. 

Andrew, M. D. - - - - 277 
New Symptom of Pneumonia. By 

Wm. M. Boling, M. D. - - 278 
Poisoning by Oil of Tansy. By 

W. W. Ely, M. D. - - - 279 



Bone in the Heart of the Bos. By 
Dr. J. L. Peirce. - - .- 279 

Case of Membranous Laryngitis. 
By Wm. M. Kemp, M. D. - 280 

The American Medical Society in 
Paris. - - - - - 283 



Domestic Summary. 

L T nunited Fracture successfully Creosote in Cholera Morbus, Cho- 
treated by Subcutaneous Per- lera Infantum, &c. By Dr. D. J. 

foration of the Bone. By Prof. Cain - - - -286 

D. Brainard. - 283 | Creosote in Diarrhoea. By Dr. T. 

Case of Enlargement of one of the M.Woodson. ... -287 

Ethmoidal Cells, resembling Ex- I Nitric Acid in Hooping-Cough and 
ostosis of the Orbit. By Prof. j Asthma. By Dr. F. C. T. Arnoldi 287 
Brainard. - - - * - - 281 External Use of Cod-Liver Oil. By 

Ligation of the Primitive Iliac Ar- Dr. A. H. David - - - 287 

tery. By Dr. A. J. Weclderburn 285 I Extract of Red Clover Blossoms 

Results of Treatment in Thirteen as a Cure for Tetter. By Dr. W. 

Cases of Pseudarthrosis. By D. Dorris. ... - 288 

Dr. Watson. - - - - 285 j Leucocythsemia. By Prof. G. B. 

Removal of a Pessary which had | Wood - 288 
remained 41 years in the Va- American Medical Association. - 28S 
gina. By Dr. Hurxthal - - 286 I 



THE 



AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JULY 1852. 



Art. I. — Medical and Surgical Notes of Campaigns in the War with 
Mexico, during the years 1845, 1846 ; 1847, and 1848. By John B. 
Porter, M. D., Surgeon U. S. Army. 

In my former paper, some reasons were given for preferring the circular 
mode of amputating limbs to the flap operation, especially in military surgery. 
They are the following : — 

The wound in the circular is not so extensive as in the flap operation; and 
in a bad atmosphere, or in an insalubrious country, this is a great advan- 
tage. 

The bone is sooner and more easily sawed through, the arteries are more 
easily secured, and the stump is more quickly and easily dressed in the cir- 
cular than in the flap operation. 

A better stump is made in the circular than in the flap operation. This is 
the strongest argument in favour of the circular mode of operating. 

Only a few cases of amputation were given in the former paper, which were 
thoi& having something peculiar in the circumstances attending them. Com- 
mon cases are of no interest, and were not included. 

Since amputation by the circular incisions is not the fashionable mode, it 
may be well to cite the opinions of a few of the most experienced authors 
on the subject, especially of those who have seen service in the field. 

Baron Larrey says : — 

" I have had opportunities of comparing the two methods ; and the uniform 
success which has followed the circular amputation has convinced me that it 
possesses more advantages than the operation with the flaps, as still recom- 
mended by some modern practitioners." — Memoirs, vol. ii. p. 102. 

Mr. Gruthrie says : — 

"I always divide the skin and fascia by the first circular incision down to 
the muscles ; they will then retract with very little assistance, from the point of 
No. XLVIL— July, 1852. 2 



14 



Porter, Surgical Notes of the Mexican War. 



the knife at particular spots of adherence, instead of the useless and painful 
dissection of the skin from the fascia, which formerly took place." — Clin. Led. 
p. 6, 1836. 

"In primary amputations, or in the natural state of parts, the loose attach- 
ment of the cellular membrane to the fascia and to the muscles beneath admits 
of much retraction of the integuments ; and when the first incision is made 
through the fascia, they retract considerably ; which is greatly increased if the 
assistant grasps the limb with both hands previously to the incision being 
made, and pulls the integuments as much upwards as possible, putting the skin 
to be divided on the stretch, and rendering its division more easy to the sur- 
geon and less painful to the patient. If the limb be also firmly grasped below, 
and the integuments made tense downwards, the division of the skin will be 
more readily effected, and so much of the integuments will be saved in conse- 
quence of the retraction upwards, that it will not be necessary to dissect them 
back in the manner recommended in many surgical works. It will be sufficient 
to separate the threads of fascia adhering below with the point of the same 
knife, to obtain an ample covering for the stump, without putting the patient to 
the torture of having his skin pinched and dissected back for the space of a 
couple of inches, and for four or five minutes. Bromfield and Alanson inveigh 
against this practice; and military surgeons during the last war proved it to be 
so unnecessary that it is now acknowledged in general to be so by those who 
formerly recommended it ; but in the adoption of it, they do not at all seem to 
be aware that the fascia and integuments should be divided by the same inci- 
sion, when the whole will retract much further than the skin and cellular mem- 
brane could do if the fascia remained to be divided by the second incision. I 
consider this simple direction to be of great importance in the saving of time 
and pain to the patient, whilst it adds to the facility with which the operation 
is accomplished, and prevents the lodgment of matter between the skin and the 
muscles, which frequently occurs in the usual method of doing this part of the 
operation." — On Gunshot Wounds, p. 274. 

But Mr. G-uthrie, it appears, operated by both methods. 

" If a cannon shot strike the back part of the thigh, and carry away the mus- 
cular part behind, and with it the great sciatic nerve, amputation is necessary, 
even if the bone be untouched ; for, although the wound might in some mea- 
sure heal, the motion of the leg would be lost, and it would become an insup- 
portable burden to the patient. In this case, I would not perform the opera- 
tion by the circular incision, but would preserve a flap from the fore part or 
sides, as I could get it to cover the bone, which should be short; I would then 
cut away the injured part, leaving a clear incised surface. The object to be 
gained by this kind of operation is to obtain a longer stump than could be made 
by the circular incision. * * * But if the injury committed on the soft parts 
does not render this possible, or enable the surgeon to save a longer stump, the 
circular incision is to be preferred." — Ibid., pp. 370, 371. 

" The flap operation ought only to be done at the upper part of the thigh, is 
very similar to that proposed for the hip-joint, and is, in some instances, pre- 
ferable to the circular incision, as it permits a longer stump to be saved, where 
the integuments are not sound in a circular direction." — Ibid., p. 383. 

" Amputation of the leg is performed in two ways : by the circular incision, 
and by the flap operation ; the circular incision being most applicable to the 
fleshy part of the leg about the calf ; the flap operation to the lower and tendin- 
ous part near the ankle, where sufficient integuments and muscle cannot be 
obtained to make a good cushion for the bones in the usual manner." — Ibid., 
p. 400.. 

"Amputation of the arm by the common circular incision is to be practised 
only in the space between the lower edge of the insertion of the pectoralis ma- 
jor and the elbow-joint. More serious wounds may be inflicted in this space, 
however, and the arm be preserved, than in any other part of the extremities." — 
Ibid., pp.512, 513. 

Mr. Gruthrie is in favour of the flap in the lower part of the forearm but 



1852.] 



Porter, Surgical Notes of the Mexican War. 



15 



" when the operation is to be performed above the middle, it is best done by 
the circular incision." 
Mr. Hennen says : — 

" I have myself, on two late occasions, performed amputation of the thigh so 
very high up, nearly embracing the trochanter, and consequently the capsular 
ligament of the joint, that a very few strokes of the scalpel would have effected 
the dislocation ; more especially, if the head and neck of the bone had been 
split to pieces, as they very often are. My incision was the common circular 
one ; and I did not, as I once before had done, make the taking up of the femo- 
ral artery a necessary preliminary measure ; I tied the arteries in succession as 
they were cut, an able assistant pressing on that in the groin." — p. 216. 

"In commencing an amputation below a joint, and particularly in a large 
lower limb, I would recommend placing the right hand under the limb, and 
carrying it to some extent round, in the position meant to commence the inci- 
sion, and then dropping the knife into the hand, instead of running the hand 
ready armed with the knife beneath the part/ 7 — p. 217. 

" By cutting the first third, or nearly so, of the circle, principally with the 
heel of the knife, we shall always be enabled to complete the external incision 
with one sweep of the instrument, a matter of some relief to the patient in point 
of pain, and of increased facility to the operator, in forming a smooth even 
edged line." — p. 217. 

" In the forearm almost every possible error of projecting bone, or insufficient 
covering, is effectually obviated by the flap operation." — p. 218. 

I have amputated the forearm at all points by the circular method, and 
never found the least difficulty in making a good stump. It is an easy opera- 
tion for the surgeon. 

Mr. Hennen was generally in favour of the circular method, for he says, in 
addition to the above remarks on amputation of the large limbs : — 

" In a small limb, I have repeatedly performed the operation with one sweep 
of the knife, cutting obliquely inwards and upwards, to the bone. The only 
objection that strikes me to operating in this mode is, that the arteries are sliced 
obliquely like a writing pen, instead of being fairly cut across, and that if this 
is not kept in remembrance, secondary hemorrhage may take place after the 
vigour of circulation is restored, in consequence of the whole circumference of 
the vessel not being included in the ligature."— p. 218. 

The slicing of the arteries obliquely like a " writing pen," instead of fairly 
cutting them " across," is an objection to the flap operation. The subject was 
alluded to in my first paper. 

&. Cooper says : — 

" Amputation is performed in the continuity of a member, or at one of its 
articulations, each of which modes, however, cannot always be practised indif- 
ferently, the choice depending upon the situation, extent, and nature of the 
disease, or injury, for which the removal of the part becomes indispensable. 
In all amputations done at the joints, it is the general practice to make a flap 
for covering the end of the bone; but when the operation is performed at an- 
other part of the limb, it is frequently at the option of the surgeon, whether the 
method adopted be amputation with a flap, or amputation by a circular incision. 
In all common instances, the latter practice receives the approbation of many 
of the best modern surgeons ; but there are particular cases, in which a devia- 
tion from this mode, in favour of the flap operation, is commendable and useful, 
as I shall hereafter notice." The notice is what follows: "The chief objec- 
tions to the operation (by the flap), when proposed as the common method, 
arise from two considerations : first, its greater pain than that of the usual 
mode ; secondly, its shortening the limb more than is necessary. Yet, all British 
surgeons agree that flap amputations are generally the best, when a limb is to 



16 



Porter, Surgical Notes of the Mexican War. 



[July, 



be taken off at a joint, and also in every instance in which the skin and soft 
parts are quite sound on one side of a member, while on the other they are 
diseased, or destroyed for a considerable extent, upwards. Here, amputating 
with a flap will be the means of preserving more of the limb than could be saved 
by the circular incision, and becomes praiseworthy on the very same principle 
which renders the latter method most eligible under ordinary circumstances." 

Mr. Syme, when a follower of Mr. Liston, used the following language : — 

" That the circular operation is tedious, every one will allow who reflects 
upon the multiplicity of its steps. First, there is the cautious circular incision 
of the skin; the change of knife; the dissection of the skin; its turning back; 
the change of knife ; the adjustment of the assistant's fingers, that they may 
not be cut off by the relentless sweep which divides the muscles ; the change 
of knife ; the separation of the muscles from the bone ; the division of the peri- 
osteum; the application of the retractors; and, lastly, the sawing of the bone." 

These are formidable charges against the circular method of amputating. 
But, instead of the " cautious circular incision of the skin," the skin and fascia 
are to be boldly divided down to the muscles ; little or no " dissection of the 
skin" is necessary; no " turning back" is required; nor is a change of knife 
thought of, excepting in peculiar circumstances. If the " assistant's fingers" are 
in the way, they deserve to be cut off; but this is a " game that two can play." 
Some years ago, I assisted an operator to amputate the thigh, by the flap ope- 
ration, near the hip-joint. My part of the performance was to command the 
artery at the os pubis, which was effectually done ; but the surgeon came near 
maiming me for life, and I begged him, in the name of a kind Providence, to 
spare my fingers, as they might be of use hereafter. This circumstance con- 
vinced me that an awkward operator can cut off fingers as well in the flap as 
in the circular method. The " separation of the muscles from the bone," if re- 
quired, may be done with the amputating knife; the "division of the perios- 
teum" may be made with the same knife; and the "sawing of the bone" is as 
necessary in the one operation as in the other. 

But Mr. Syme speaks of the two methods (Monthly Journ. of Med. Sci., 
Nov. 1846) very candidly, as follows; — 

" Notwithstanding the share I took in introducing the flap operation, and the 
confident persuasion of its superiority formerly entertained, I have long felt 
occasion to point out some serious inconveniences apt to attend its performance: 
and I am now satisfied that there are circumstances in which the circular in- 
cision ought to be preferred." 

After giving the arguments for and against each method of operation, Mr. 

Syme goes on to say : — 

"In subjecting these various arguments, on both sides of the question, to the 
test of experience, it may be remarked that they are not all of equal value ; 
some of them relating to matter of mere convenience, while others regard con- 
sequences of the most serious nature. The great questions at issue are, which 
operation least endangers the patient's life ? and which affords the most com- 
fortable stump ? Now, every one who has witnessed the flap operation exten- 
sively and indiscriminately for amputation of the thigh, must have seen a large 
proportion of deaths, and in the event of recovery, not unfrequently a condition 
of the stump no less unsightly than inconvenient. Such are the undeniable 
facts, and their explanation presents little difficulty to any one who has had 
sufficient opportunity of observation. 

" So far as the mere performance, or early consequences of the flap operation 



1852.] 



Porter, Surgical Notes of the Mexican War. • 17 



are concerned, nothing can be more satisfactory. The incisions are executed 
almost instantaneously, and the whole process is completed with a degree of 
facility, dispatch, and ease to the patient that presents a remarkable contrast, 
when compared with the circular method. 

" When the flaps are placed together, it seems as if nothing could prevent 
their perfect union, so as to effect a speedy cure, and afford a comfortable cover- 
ing to the bone. In some cases these favourable anticipations are fully realized ; 
but, though a good many days, and even one or two weeks, may elapse without 
making manifest the disappointment to be experienced, it much more frequently 
happens that the soft parts, however ample they may have appeared in the first 
instance, gradually contract and diminish, until care is required to keep their 
edges in apposition over the bone, which sometimes, notwithstanding every 
precaution, at length becomes denuded, and presenting itself to view, whether 
dead or living, proclaims the unavoidable misery of a sugar-loaf stump. This 
distressing result depends upon the vital contractility of the muscular tissue, 
which, continuing in operation so long as the cut surface is not prevented from 
yielding, by the formation of new adhesion, not only lessens the mass of flesh 
provided for covering the bone, but gradually retracts it together with the super- 
jacent integuments. The effect thus produced is favoured by the following 
circumstance. In the first place, by cutting the flaps of such moderate length 
that, when brought together, they merely meet without straining ; secondly, by 
sawing the bone where it is exposed, by simply separating the flaps, instead of 
drawing the muscles back, so as to divide it at a considerably higher point; 
and thirdly, by performing the operation at the lower third of the thigh. Mr. 
Liston recommends amputating at the middle of the bone, upon the ground of 
thus forming a more convenient stump for the attachment of an artificial limb, 
than would result from operating at a lower point. For my own part, I have, 
during many years past, advised this, to prevent the great risk, or almost cer- 
tainty of protrusion, to which the bone is exposed when divided at or near its 
lower third. But the flap operation being thus objectionable below the middle 
of the thigh, and even higher up, seldom in the end furnishing more than a 
covering of skin to the bone, it may be inquired, how far the circular method 
deserves adoption in amputation at the lower third ? 

" The true object of the circular incision is, to provide a covering of skin for 
the bone ; and a great error has been committed by many, indeed almost all 
the would-be improvers of this operation, in directing their attention to modify- 
ing the division of the muscles, as if any form of their section could materially 
influence the result. All the attempts with this view have been directed so as 
in one way or other to give the cut surface of the muscles a conical form, evi- 
dently under the impression that they serve to assist in covering the bone. 
Now, it is quite clear that, if the ample masses of flesh afforded by the flap 
operation yield to the retractile agency of their tissue, the scanty portion ob- 
tained by any form of circular incision cannot have the slightest effect in im- 
proving the condition of the stump. These wrong-directed efforts would have 
doAe no harm, unless they had withdrawn attention from what was really 
required to render the result satisfactory. In this way, however, they have 
seriously opposed improvement, and in my own case, I confess, long prevented 
the truth from being distinctly seen. 

" The perfect condition of the stump resulting from amputation at the ankle, 
where there is nothing but integument to protect the bone, led me to conclude 
that, if the circular operation could be performed with the certainty of providing 
such a covering, it might be employed with advantage in the lower third of the 
thigh ; which, being the thinnest part of the limb, most readily admits of forming 
a stump composed merely of skin. There is, also, in operating here, plenty of 
room to apply the tourniquet without impeding the incisions or retraction of the 
muscles, and the size of the wound inflicted is, of course, much smaller than of 
an amputation at the middle of the thigh. In the course of the summer, I have 
performed the operation four times, on adult persons, with the effect of confirm- 
ing the favourable expectations which the considerations just mentioned had 
led me to entertain; and I now feel warranted to advise that, whenever a case 



18 Porter, Surgical Notes of the Mexican War. P^ty? 

requiring amputation of the thigh, admits of the limb being removed at its 
lower third, the circular method should be employed. 

" The compress of the tourniquet should be applied over the artery close to. 
the groin. Instead of the old-fashioned, concave-edged, thick-backed amputat- 
ing knife, a middle-sized one of the kind employed for the flap operation will 
be found more convenient. The incision of the skin should be made as near 
the knee as possible, not in a circular direction, but so as to form two semilunar 
edges, which may meet together in a line from side to side, without projecting 
at the corners. The fascia should be divided along with the integuments, which 
are thus more easily retracted — not by dissecting and turning them back, but 
by steadily drawing them upwards, through means of the assistant's hands 
firmly clasping the iimb. This should be done to the extent of at least two 
inches, or more, if the thigh is unusually thick. The muscles are then to be 
divided as high as they have been exposed, by a circular sweep of the knife, 
directly down to the bone, from which they must be separated and retracted 
with the utmost care. In ordinary circumstances, the retraction should not be 
less than two inches, and, before using the saw, the bone must be completely 
exposed by means of a cloth split up the middle, applied on each side of it, and 
forcibly held up. 

" If due attention be paid to these directions, I feel confident that amputa- 
tion by circular incision at the lower third of the thigh will afford satisfactory 
results ; and should, therefore, be preferred to the flap operation at a higher 
part of the limb when the circumstances afford room for choice. Where it is 
necessary to amputate at or above the middle of the bone, there can be no ques- 
tion as to the propriety of operating by the flap method. " 

"Before arriving at the conclusion which has just been explained, I thought 
that amputation at the knee might be employed with advantage, as a substitute 
for the flap operation at the middle of the thigh ; and my own opinion would 
still be so if this alternative afforded the only room for choice. I operated at 
the knee with complete success in three cases ; two of which were diseases of 
the joint; and the other a recent injury from the leg having been torn off by 
machinery. But as the soft parts required to form the stump in this situation 
are apt to be so deranged in their texture as to delay, though not prevent 
recovery, and thus in some measure counterbalance the advantage of exposing 
cancellated instead of dense bone, together with the contents of its medullary 
cavity, I do not persist in advocating amputation at the knee, now when satis- 
fied that the operation by the circular incision, if performed with due care on 
proper principles, may be employed at the lower third of the thigh safely and 
advantageously." 

The long extracts from Mr. Syme's able paper are warranted by the import- 
ance of the subject, and they deserve serious consideration. The important 
questions are 

1. Which operation least endangers the patient's life? 

2. Which affords the most comfortable stump? 

The contractility of the muscular tissue produces a bad stump in the flap 
operation, while the contractility has no effect in the circular method. Why 
is this ? It is owing to the union of the skin, fascia, and muscular fibre in 
one mass in the flap operation, and to the separation of the skin and fascia 
from the muscle in the circular method. The contractility of the muscle 
separates the whole flap, skin, fascia, and muscle completely from the bone; 
while the muscular tissue in the circular mode may contract to such a degree 
as to allow the bone to project beyond it; but this is of little consequence, 
for the skin and fascia still form a covering. As Mr. Syme says : "The true 
object of the circular incision is to provide a covering of skin for the bone." 



1852.] 



Porter, Surgical Notes of the Mexican War. 



19 



Let this be kept in view in amputation of the thigh ; save plenty of skin and 
fascia together ; cut the muscles high up, and directly down to the bone if 
you please ; perhaps sever them somewhat from the bone with the point of the 
knife j and raise them well up with the retractor before sawing the bone. By 
attending to these particulars, with the grand object of the circular incision in 
view, it is scarcely probable that the bone will project in the progress of the 
case. The radical difference between the two operations consists in the for- 
mation of the covering for the bone, which is principally muscular in the true 
flap operation, producing inconveniences and serious consequences; while the 
flap or covering of the bone by the circular incision is formed principally of 
skin, cellular substance, and the fascia. To attain the object of throwing out 
the muscular tissue, so that its contractility can exert little or no influence on 
the covering of the bone, is worth all the trouble which the opponents of the 
circular incision bring so prominently forward, even to the repeated changes 
of the knife. This is the great distinction between the circular and the flap 
operations. In my first operation above the knee, I was greatly troubled 
about the result, fearing there was not sufficient muscle, though there was 
plenty of integument ; but the result was highly favourable. Had I reflected 
on the subject, my mind would have been at ease, and at the present time I 
would throw all fears of a bad stump, ulceration, projection of bone, &c, to 
the winds. 

Mr. Liston, however, does not deign to give a description of the circular 
method of amputation in his Elements of Surgery, notwithstanding the respect- 
able names in its favour ; but seems to consider his dictum fully sufficient to 
settle the question. Mr. Liston says : — 

"Hitherto these general observations on amputation have regarded the flap 
operation only ; the circular method has not been mentioned. The reason is, 
that the circular amputation has been, it is hoped, in a great measure aban- 
doned in this country. And its inferiority to the method by flaps is so obvious 
and so generally acknowledged, that detail of the different steps of the opera- 
tion is, I conceive, here altogether unnecessary. It is more tedious in per- 
formance, more painful to the patient, does not afford so good a covering for 
the end of the bone, and consequently not so convenient and useful a support 
for an artificial limb, and the cure of the wound is protracted. The stump is 
aMost always conical, the end of the bone is, ultimately at least, covered only 
by integument, and from even very slight pressure this is apt to ulcerate ; exfo- 
liation of the bone follows to a greater or less extent, or unhealthy ulcer of the 
soft parts continues along with caries of the bone, and partial death of its sur- 
face ; and at length it becomes necessary to either perform a second amputation, 
or to curtail the length of the bone. It may sometimes succeed tolerably well 
when there is but one bone ; when there are two, it is altogether inadmissible. 
In very muscular limbs, when amputation is demanded on account of destruc- 
tion of the bones and joints, with laceration of the soft parts, as when the pa- 
tient is not required to have pressure made on the stump, it suits well to make 
the flap of integument only, and to cut the muscles short, as will be noticed 
more fully. The advocates for the circular amputation, my excellent friend, 
Sir George Ballingall and others, wish it to be believed (and this is their main 
argument), that the exposed surface of the flaps is much greater than that in 
their favourite method. Some of the philosophers of the modern Athens have 
been applied to, and have measured, it is said, the area of the one and the 
other, and given their verdict in favour of the roundabout incision." 



20 



Porter, Surgical Notes of the Mexican War. 



The advocates for the circular amputation may not wish to take anything 
on trust, not even the views of Mr. Liston ; but it is to be hoped they are 
willing to permit every one to enjoy his own deliberately formed opinion; 
Fifty or one hundred years ago, some acknowledged leader might have dic- 
tated to the whole body of the profession ; but those days have fortunately 
gone by. It is to be regretted that Mr. Liston did not remember this, and 
recollect that the time had passed when men and measures, if they did not 
square with the dictator's ideas, might be, in the classic language of Mr. 
John Hunter, easily " cracked like so many vermin as they come before me." 
In the present age the profession acknowledges no leader. Nullius addictus 
jurare in verba magistri. 

Let us look at Chelius : — 

"As regards the preference of the several modes of proceeding in amputation 
of the limbs in their continuity, I must, according to my own experience, pre- 
fer amputation by the circular cut, and that method indeed, in which the skin 
is divided and drawn back, and at its edge the cut carried vertically through the 
muscles down to the bone, and then the muscles still remaining attached to the 
bone cut through still higher, and thus a conical surface of wound formed. 
The superior advantages ascribed to the flap operation, to wit, abetter covering 
of the stump with muscle, more speedy union, and therewith a shortening of 
the cure, over the circular operation just recommended, are groundless. In 
reference to the first point, Bruninghausen makes a remark which I have also 
observed, that the covering of the stump with muscle may indeed be effected at the 
moment of union and for some time, but that after a longer period the bone is 
merely covered with skin." 

The italics are my own. At this point Mr. South remarks : — 

[" This observation, as regards both flap and circular amputations, will be 
found confirmed by every one who examines a stump a sufficient length of time 
after its complete healing."] 

" On the other hand, after amputating the thigh with merely saving skin, I 
have never seen protrusion of the bone. But it must be held as an objection to 
flap operations that tying the vessels which are obliquely cut through, and often 
wounded in several places, is more difficult, and the number of vessels to be 
tied is always greater than with the circular cut, that the wound is larger, and 
therefore, if union do not take place, wasting suppuration is to be earlier 
feared. In other respects, I do not consider the dispute as to the preference of 
the circular or flap operation of so much consequence as many do, as I am con- 
vinced that the successful result depends not merely on the mode of operation, 
but on the manner of its performance, and especially on the proper conduct of 
the after treatment. The flap operation, however, must always be considered 
more suitable when the amputation is performed at the upper third of the thigh ; 
when the limb cannot be brought into a proper posture for performing the cir- 
cular cut, and when the destruction of the soft parts is such that by the flap 
considerable saving may be effected." — South' s Chelius, vol. iii. p. 651. 

Mr. South remarks : — 

"As regards these serious objections to circular operations, I must observe 
that, in the large hospital with which I am connected, for many years I scarcely 
ever witnessed the performance of any other than circular amputations, except 
on the forearm, and that the ugly consequences which Liston has detailed were 
of great rarity, and not, I believe, attributable to the mode of operation. Of 
late years, however, more flap operations have been performed among us than 
previously, and probably their relative number is now about the same. I have 
performed about an equal number of each, and the result has been so nearly 
the same that,, in most cases, I hardly think one is to be preferred to the other. 



1852.] 



Porter, Surgical Notes of the Mexican War. 



21 



The flap operations are more smart and showy in their performance, but in their 
result may be as untoward and unsatisfactory as circular operations have been 
stated to be." — South' s Chelius, vol. iii. p. 653. 

"At a meeting of the Reading Pathological Society, Mr. Bulley read a short 
paper on some of the disadvantages which he considered to attend the flap ope- 
ration for amputation. He thought it was a much more painful operation than 
the circular one, and that, in the aggregate, it took a longer time in the per- 
formance. More painful from the greater extent of the integument divided, 
and from the oblique incision of the nerves ; and longer in performance from 
the oblique section of the vessels, rendering them unable to collapse, and thus, 
with a greater difficulty in securing them, a greater number of arteries required 
ligature. An eminent surgeon in London had mentioned to him that he had 
been obliged to apply twenty-five ligatures after a flap operation in which there 
was reason to believe that, had the circular method been employed, three or 
four might have been sufficient." — 1846. 

Mr. Rutherford Alcock has found, with reference to the main question of 
comparative mortality, that his results are by a fraction disadvantageous to 
flap amputations. He is not, therefore, prepared to agree in what was said to 
be the growing opinion, that this operation would in time completely super- 
sede the other. — 1841. 

Sir George Ballingall says : — 

"I know of no comparative estimate of the results of amputations performed 
by the circular incision and by the double flap, which will enable us to decide 
their respective merits by the test of experience ; but in instituting any compa- 
rison between these operations, one of the first circumstances which strikes a 
surgeon is the different extent of cut surface left by the one operation and by 
the other. It has long appeared to me that the difference in this respect is 
much greater than many surgeons are aware of ; and I have often remarked 
that the extent of cut surface exposed by the double flap operation appeared to 
me nearly double that left by the circular incision. I was not, however, aware 
until very lately that in making this statement I was so near the truth." 

" It is not, however, the extent of cut surface alone that seems to me an 
objection to the flap operation, but in proportion to the extent of this surface is 
the number of vessels requiring ligature ; in amputation of the thigh, for in- 
stance, when the operation is undertaken for long-standing disease of the knee- 
joint, and performed very low down, we have the flaps, particularly the extreme 
points of them, often highly vascular ; and it is no uncommon thing to find 
from eight to ten vessels requiring ligature, whereas half this number is the 
more usual proportion in the circular operation. It will be easily understood 
that a vessel which requires a ligature in the lower edge of the flap may, in its 
progress towards it, have given off several branches, each of them requiring the 
same security, and many or all of which would have been removed along with 
the distal part of the limb by the circular incision. It will also be understood 
that in operating by the double flap the bloodvessels are often cut obliquely; 
sometimes, indeed, they may be seen scooped like a writing pen ; and although 
this maybe of no great moment when these vessels are carefully and accurately 
secured with ligatures, yet this is obviously a division of the vessel unfavour- 
able to its retraction and rapid closure ; and if in consequence of the faintness 
of the patient, a vessel should not bleed, and not be secured at the time of the 
operation, it will be more liable to bleed afterwards when the patient rallies 
and the blood returns perhaps with increased impetus to the wounded point. 
In proof of this, I appeal to the observation of my colleagues here, where the 
flap operation has been almost exclusively performed for many years past. 
Hemorrhage perhaps scarcely coming under the usual description of secondary 
hemorrhage, but occurring a few hours after the patient is laid in bed, is an 
almost every-day occurrence; in fact, the practice of delaying the complete 
dressing of a stump for several hours after the operation has been advocated, 
in addition to other reasons, upon the ground of its affording a facility to meet 



22 



Porter ; Surgical Notes of the Mexican War. 



this sort of secondary hemorrhage. In one case I have seen nine vessels secured 
upon the table, and eleven afterwards ; and in a very recent case, we had eight 
or nine vessels secured before the patient left the operating table, and the same 
number within an hour afterwards, in consequence of hemorrhage from the 
stump. A very striking illustration of the liability of flap operations to second- 
ary hemorrhage has been mentioned to me by Mr. Alcock, who states that ' in 
two cases at Vittoria of double amputation, one leg in each was amputated by 
flap, and another by circular incision ; from the former in both patients there 
was secondary hemorrhage, and from neither of the latter.' ;; 

" The state of the nerves in flap operations is another most important conside- 
ration ; the remark I have made as to the ramifications of the arteries will in 
some measure apply to the nerves, and we sometimes see large portions of 
nerves exposed upon the surface of the flap, or projecting loosely frorn it." 

"The nest point of view in which the two operations may be compared is 
the covering left for the extremity of the bone, and the favourable state of the 
parts for an accurate approximation, and speedy healing of the wounds. In 
both these respects the comparison is highly in favour of the flap operation, 
according to the views entertained, and the practice followed by the surgeons 
of this country; but should circumstances occur to prevent union by the first 
intention, it is obvious from what has been said that the flap operation leaves a 
larger quantity of suppurating surface. Facility and rapidity of execution are 
seldom a fair ground of preference for one operation over another ; and can 
never be so when other important considerations are to be sacrificed to them ; 
it is indeed possible to conceive cases, particularly in military or naval life, 
where, ceter is paribus, the saving of time may be an object ; but the rapidity with 
which the flap operation can be executed has, I fear, been sometimes made a 
ground of preference where no such motive existed ; and I cannot divest myself 
of the suspicion that the feeling of rivalship has in some measure led to the indis- 
criminate practice of flap operations. It is not every young surgeon who can 
stand by undisturbed and hear it said, and hear it repeated that his colleague 
will amputate a limb in so many seconds, while he requires perhaps as many 
minutes. The flap operation is a seductive one, and I speak from my own experi- 
ence when I say that it is an operation which one is unwilling to relinquish after 
having once experienced the comparative facility of its execution. It will be 
seen, however, that I am quite prepared to discriminate between those cases in 
which the flap is to be considered the preferable operation, and those in which 
the circular incision is the best. I ma}^ here state generally that in operations 
at the joints, the adoption of the flap operation is calculated to facilitate the dis- 
articulation of the bone; and in coming to particulars I would specify the 
shoulder and hip-joints, the forearm, and the leg, as cases in which this opera- 
tion is decidedly preferable ; but I am by no means prepared to admit its exclu- 
sive advantages in operating on the arm, and still less in operating on the 
thigh. These seem to me the principal points of importance in a general com- 
parison of the two operations." 

The foregoing extracts must serve to convince the disciples of Mr. Liston 
that the " inferiority to the method by flaps" is not so "generally acknow- 
ledged" as the Elements of Surgery might lead us to suppose. Mr. Guthrie's 
description of his method of amputating in the Peninsula bears on the sub- 
ject. 

" 1. I did not use a tourniquet, the screwing and unscrewing of which always 
create some difficulty and annoyance. I never do when I have good assistants, 
but you must have recourse to it when alone or when they are ignorant. A 
very moderate and simple pressure suffices to stop the flow of blood through the 
largest artery. 

" 2. I always divide the skin and fascia by the first circular incision down to 
the muscles ; they will then retract with very little assistance from the point 
of the knife at particular spots of adherence, instead of the useless and painful 
dissection of the skin from the fascia, which formerly took place. 



1852.] Porter, Surgical Notes of the Mexican War. 23 

"3. You will find in books that, in dividing the muscles, you are to take par- 
ticular care that you cut the long and unattached ones of a different length 
from those which are attached to the thigh bone, and each muscle according to 
its power of retraction ; so that they must be cut long and short, and of different 
lengths, something like the parts composing the compensation pendulum of a 
clock. I have no objection to all this ; but I never saw it done, and have long 
since given up all thoughts of doing it myself ; and why ? because I have seen 
scores of amputations done by all sorts of hackers, hewers, and bunglers, and 
I invariably found that no matter how they were hacked or hewed, whether the 
muscles were cut according to compensation principles or not, they always 
made capital stumps when another rule was observed, viz., to cut the bone, 
that is, to have it well covered by these same muscles and integuments. It is 
the golden rule of amputation, and the quicker you can do everything else and 
come to that, the better for your patient. 

" 4. Saw your bone perpendicularly, and not slantingly, which prevents its 
splintering. " — Clinical Lectures, p. 6. 

An operation performed in the manner above described can scarcely pro- 
duce a bad stump. In the thigh, the integuments being well drawn up, let a 
rapid circular incision be carried down to the very muscle; let another sweep 
. (the integuments being well drawn up) be carried down to the very lowest 
muscles j let another sweep (with the integuments and superficial muscles well 
drawn up) divide the deep-seated muscles down to the bone ; and then let the 
divided parts be well drawn up by the retractor, and the bone sawed through 
in the manner stated by Mr. Guthrie, and a bad stump will rarely occur. It 
may be advisable, in fleshy parts like the thigh, to save plenty of muscle, as 
recommended by Mr. Guthrie; but, according to Syme, Chelius, and others, 
this is of little consequence, provided sufficient integument be preserved to 
cover the bone. Indeed, "the perfect condition of the stump resulting from 
amputation at the ankle, where there is nothing but integument to protect the 
bone, led me to conclude," says Mr. Syme, " that, if the circular operation 
could be performed with the certainty of providing such a covering, it might 
be employed with advantage in the lower third of the thigh; which being the 
thinnest part of the limb, most readily admits of forming a stump composed 
merely of skin." If there be not sufficient muscle in a limb to cover the 
bone, it is of little consequence. 

In amputation of the leg, some surgeons, who are in favour of the circular 
method in all other limbs, prefer the flap operation, But the gastrocnemius 
is a powerful muscle, and by its contractility may give trouble in the course 
of cure. " So far as my own experience proves," says Mr. South, " flap ope- 
rations, in the continuity of the bone, may be performed as successfully as 
circular operations on every limb but the leg, in which the calf muscles are 
so bulky that it is often difficult to get the skin well over them, if they be 
left, and I do not think the cure is so quick as with the circular. But if a 
skin flap be made, and the muscles cut through directly, I do not think more 
time is gained than by the circular operation. There is, however, a more se- 
rious objection to flap operation through the calf, in the greater frequency of 
after-bleeding ; this has occurred to me two or three times, and the number of 
vessels I have had to take up, and the sloughy condition of the whole flap, and 



24 



Porter, Surgical Notes of the Mexican War. 



its tedious union by granulation, have almost induced me to determine never 
to operate on the leg but with the circular." — iii. p. 654. 

In the arm and forearm, the operation by the circular incision is very rapidly 
performed by one sweep of the knife down to the muscles, and another sweep 
to the bone. In the hand and foot, the flap operation is preferable, for the 
best of reasons — there is no muscular tissue in the flap to interfere with the 
cure. It is in principle, therefore, a circular operation. Major , volun- 
teers, was badly wounded in the hand at Monterey, on the morning of the 
24th of September, 1846, after hostilities had ceased, by the accidental dis- 
charge of his own pistol. The index and part of its metacarpal bone, and 
the middle finger at the joint, were taken away by the flap operation, and the 
patient was cured in a surprisingly short period of time. He was never 
admitted into hospital, but came to me every day to have the wound 
attended to. One reason why operations on the hand are more successful 
than those on the foot is, that the patient is able to take regular and gentle 
exercise. 

There are certain cases in which amputation by the flap is preferable to 
the circular method, forming the exceptions to the general rule in favour of 
the latter. They are, 

1. Amputations at joints. 2. Near the hip-joint, in the upper extremity 
of the thigh. 3. When the limb cannot be brought into a proper posture for 
performing the circular cut (Chelius). 4. When the destruction of the soft 
parts is such that by the flap operation considerable saving of the limb may 
be effected. 

If I am not greatly mistaken, the members of the medical department of 
the army were in favour of the circular method of operating in Mexico. Some 
of the best operators in our corps amputated in this manner; and one of them, 
who served in the field from Corpus Christi to the surrender of the city of 
Mexico, and who was an advocate of the flap operation, and practised it at 
the beginning of the war, informs me that he changed both his opinion and 
practice, on the ground that the stump made by the circular operation is the 
best. His name would be gladly given were I at liberty to do so, but it is to 
be hoped that he will give the results of his experience. Whatever may be 
the experience of others, my own opinion is decidedly in favour of the circular 
method. 

In the American Journal for October, 1848, is a communication from Dr. 
M. G-. Delany, Surgeon U. S. Navy, in relation to Mr. Syme's practice; and 
I am glad to see that the medical officers of the other arm of our service have 
taken the subject into consideration. And I must again be permitted to re- 
commend Mr. Syme's able paper to the further notice of the profession, espe- 
cially to military surgeons. Hereafter, if the country should be so unfortunate 
as to become involved in war, I shall be prepared to operate, mostly, by the 
"roundabout incision. ,; 



1852.] 



Porter, Surgical Notes of the Mexican War. 



25 



Amputation at Joints. — Amputation in the contiguity of limbs is much 
praised by several writers of high authority. Baron Larrey operated several 
times at the joints at the battles of Eslingen and Wagram, and "experience 
has since taught me," says he, " that amputation at the joints in recent inju- 
ries is more successful, ceeteris paribus, than amputation when performed in 
the middle or continuity of a limb." * * * >:< " Finally, I do not hesi- 
tate to assert that nine of ten cases will succeed, where amputation has been 
performed at the joint; while two-thirds of the same number will scarcely 
survive, when the operation is performed in the continuity of the limb." This 
is certainly strong language, by one of the most experienced military surgeons 
of the age. According to Larrey's views, amputation at the hip-joint ought 
to be much more successful than the operation at the upper part of the thigh, 
and it may be, for aught I can prove to the contrary. 

M. Sedillot says that — 

" Amputation at the elbow-joint was adopted, and, if we may so speak, legal- 
ized by M. Dupuytren. It is declared by M. Yelpeau to be less dangerous than 
amputation of the arm in its continuity, but M. Sedillot justly thinks that we 
are not as yet possessed of a sufficient number of facts to substantiate this state- 
ment, and prefers, in all cases, removal of the arm according to the common 
method." — Dr. Norris, in Am. Journal, vol. xxi. p. 437. 

It is fortunate that the ball-and-socket joints are so simple in their con- 
formation, for it is often essential to the preservation of life that amputation 
should be performed at the hip and shoulder. The ginglymoid joints are more 
complicated, and are more liable to accidents than the others, but the neces- 
sity for the operation is not so imperious, and we have an election. Instead 
of amputating at the ankle-joint, we may operate just above; instead of the 
operation at the elbow, we may amputate just above or below the joint; and 
it will be a long time before I would undertake an operation at the knee, not- 
withstanding the authority of Larrey, Syme, Dupuytren, Yelpeau, and other 
eminent surgeons. 

Amputation, primary or secondary? This question has been, and continues 
to be, an important one in military surgery. It is well known that M. Faure, 
who was an advocate for delaying the operation, received the medal of the 
French Royal Academy of Surgery, after the battle of Fontenoy, for his essay 
on the prize question — " Is it advisable to amputate immediately after gun- 
shot wounds, or should the operation be deferred ?" Afterwards, Bilguer, 
surgeon-in-chief of the Prussian army, and Sch mucker, his successor, held the 
same opinion. Subsequently, John Hunter, who, on military surgery, " led 
to bewilder, and dazzled to blind," came upon the stage, and by his influence 
and authority extended the doctrine, in a great measure, to the present day. 
Among the moderns who have treated of gunshot wounds, M. Malgaigne and 
M. Gosselin, his colleague, and Mr. Rutherford Alcock, hold to the same 
opinions. For M. Malgaigne* s statistics, &c, see Am. Journ., vol. xvi. p. 
458, Oct. 1848. M. Malgaigne's general conclusion is that, in " attempting 
to preserve the limbs of the wounded, the surgeon does not cause them to 



26 Porter, Surgical Notes of the Mexican War. [July? 

incur any greater risks than if amputation were performed." The views of 
Mr. Alcock are well known to the profession. 

But M. Faure gave a pretty large list of exceptions to his general rule ; for, 
where a member has been carried away, an important articulation violently 
fractured — the bone of an extremity shattered, with extensive destruction of 
soft parts, or the bones have been minutely comminuted and surrounded by 
a considerable contusion of the soft parts, with laceration of the tendons and 
aponeurosis — where the structures of the large joints are torn, and the bones 
are fractured, and where the main artery is lacerated and the hemorrhage can- 
not be controlled, it would be dangerous, in M. Faure's opinion, to defer an 
operation. 

Baron Larrey gives the following reasons for immediate amputation on the 
field of battle : — 

" 1. The inconvenience which attends the transportation of the wounded from 
the field of battle to the military hospitals on badly-constructed carriages ; the 
jarring of the wagons, &c. 

"2. The danger of remaining long in the hospitals. This risk is much di- 
minished by amputation. 

"3. In case the wounded are of necessity abandoned on the field of battle/ 7 

Larrey states that, in the terrible battle with the British fleet under Lord 
Howe, 1794, the chief surgeon of the Jemmape amputated immediately, and 
was successful ; while the surgeon of the Temeraire (taken by the English), 
by the advice of their surgeons, postponed the amputation of which many were 
in need, until they should arrive in port; but they all died on the passage. 

" During the war in North America, in 1780, the surgeons of the French 
army performed a great number of amputations according to the prevailing 
opinion in France, that an operation should not be attempted until the primary 
symptoms have ceased. The Americans, on the contrary, who had the courage 
to amputate immediately, or within the first twenty-four hours, where their 
wounded required it, lost but a very small number: and yet, M. Dubor, then 
surgeon-major of the Artois dragoons, of whom I learned the fact, asserts that 
the condition of the hospital in which the wounded French were accommodated, 
was in many respects superior to that where the wounded Americans were 
placed." — Memoirs, vol. ii. p. 109. 

Dr. Mann, Hospital Surgeon U. S. A., in the war of 1812 {Medical 
Sketches), adopting the opinions of Faure, Bilguer, and Hunter, was an advo- 
cate for delay. It is interesting to trace the apparent reasons. According to 
M. Dubor, the Americans were eminently successful in their operations in 
1780 ; but they had been acquiring knowledge from 1775, at Bunker's Hill, 
and Long Island, in New Jersey, at Brandywine, Saratoga, &c, or they were 
poor scholars ; and whatever their views might have been at the commence- 
ment of the war, notwithstanding the bad state of funds, and want of all things 
which seem essential, they succeeded much better than the French surgeons, 
who were influenced by the prize question, and the decision of the Royal 
Academy. But the French Revolution, and the tremendous wars on the con- 
tinent of Europe, overturned all these notions. On the contrary, our surgeons 
had no experience in 1812. Our country had been in profound peace since 



1852.] Porter, Surgical Notes of the Mexican War. 27 

1783, and the dogmas of J ohn Hunter had full sway. Hence (it is presumed) 
the opinions and practice of Dr. Mann, though other surgeons in our service 
at that time might not have been of the same opinion. 
Mr. Guthrie on the same subject: — 

" It is not sufficient to perform twenty amputations on the field of battle, and 
contrast them with as many cases of amputation done at a later period. The 
twenty cases for delayed operation must be selected on the field of battle, and 
their result compared at the end of three months with that of the others ; when 
the value of the two modes will be duly estimated." 

Mr. Guthrie gives the following official statement of mortality : — 

Secondary. Primary. 

Upper extremities, 12 to 1 

Lower 3 to 1 

" Many bad wounds will never reach this secondary stage, especially in the 
summer season ; and, if the patients outlive the first symptoms, they will not 
outlive the operation/'— Gunshot Wounds, p. 238. 

The question is well stated in Druitt's Surgery — 

"It must be recollected that the question is, not whether a hundred men just 
wounded, and requiring amputation, are more likely to survive it than a hun- 
dred who have gone through the ordeal of six weeks in a hospital; but whether 
the first hundred would live to that period ; which most probably they would 
not." 

Larrey says : — 

" If Faure still has followers, I invite them to repair to the field of battle 
during an engagement. They will then soon be convinced that, without primi- 
tive amputation, a great number of the wounded must die. In Egypt, this 
truth was most completely demonstrated." 

Mr. Hennen says : — 

"Finally, the results of the field amputations, after the battle of Waterloo, 
confirm the published experience of both these writers (Larrey and Guthrie), 
and it is to be hoped that the question is now set at rest forever." 

A year or two previous to the breaking out of the war with Mexico, I 
listened to a lecture on this subject from a professor of surgery in one of 
our medical schools ; and he gave his opinion, that military surgeons were 
disposed to look with great favour on secondary amputations. His principal 
authority was Mr. Rutherford Alcock. This circumstance has induced me to 
devote more space to the question than would otherwise have been done. I 
venture to say that no rule was more universally acted upon by the surgeons 
of our army in Mexico, from the battle of Palo Alto to the treaty of peace, 
than the one laid down by Hennen : " With as little delay as possible." In 
the words of Hennen: "While hundreds are waiting for the decision of the 
surgeon, he will never be at a loss to select individuals who can safely and ad- 
vantageously bear to be operated on as quickly as himself and his assistants 
can offer their aid." This was the decided practice of every medical officer 
with whom I served during the war. (See Hennen, pp. 55, 56, 57, 58 ; Guth- 
rie, pp. 216-232.) 

Certain wounds are received on the field of battle, in which it is difficult to 



28 Porter, Surgical Notes of the Mexican War. [July? 

decide whether amputation is the proper practice, or not. If the operation be 
not performed, the patient will certainly die ; but reaction never comes on. A 
private of the fifth infantry regiment was wounded at Monterey on the morning 
of the 21st of September, 1846, by a shell which struck the lower part of the 
thigh. The shock to the system was great, and reaction did not come on; but 
the patient suffering great pain, we determined to amputate, hoping that he 
would improve after the operation. Drs. Conrad, De Leon, and myself took 
off the limb at the upper part of the thigh; but the operation was of no avail, 
and the patient died that night. These are trying cases. The instance of Gen. 
Daboville, related by Larrey, affords some slight encouragement for the opera- 
tion under these circumstances. Perhaps the best course would be — if nearly 
certain that death must take place, unless the operation be performed, and we 
can be tolerably sure the patient will live through it — to amputate : but it is 
a most important question. Occasio prseceps, judicium difficile. 

Dressing of the stump after amputation. — Having alluded to sutures in the 
former paper, it may be well to briefly state the mode of dressing. Sutures 
were always employed; numerous enough to bring the edges of the wound 
into complete coaptation in the whole line of the incision, and adhesive straps 
were afterwards applied to assist the stitches by preventing too much weight 
from resting upon them. I have never known them produce so much irrita- 
tion as to require removal before the proper period for the first dressing ; and, 
by the time this is necessary, the wounded can be collected, and the hospitals 
formed, when such stitches as are not necessary may be removed. By this 
time, the wound may be united in its whole extent. Adhesive plaster, per se } 
was never relied upon. On no account was a stump dressed without stitches, 
and incised wounds of every kind were treated in the same manner. The 
cold water dressing, or lead water, may be employed, if considered necessary; 
but in very many cases nothing but perfect rest is required, with light cover- 
ing to the wound, until the patient recovers. I consider stitches absolutely 
necessary in military surgery, on account of the frequent removals to which 
the wounded are subjected during and after engagements, often in wagons of 
the roughest kind. Indeed, I am in favour of them in almost all circum- 
stances, the scalp always being excepted. 

In regard to authority, Chelius is opposed to sutures; Mr. South thinks the 
surgeon may " use his own discretion Mr. Syme says they may be employed 
"if necessary;" and Mr. Liston gives the following opinion : " If such means 
(adhesive straps) be considered insufficient, recourse must be had to a few 
points of interrupted suture, and these are not productive of the bad conse- 
quences which have been by some attributed to them. When neatly applied, 
they can produce but little irritation, more especially if removed as soon as 
their presence is unnecessary; that is, as soon as adhesion has fairly commenced, 
and the natural bond of union is of such strength as to need no artificial as- 
sistance. By these the edges of the wound are more neatly and suitably 
placed than by any other ; they meet easily, without the puckering or over- 



1852.] 



Porter, Surgical Notes of the Mexican War. 



29 



lapping of each other ; and from the circumstance of sutures obtaining a more 
just coaptation, they can be sooner discontinued. In most wounds, no other 
dressing is required; but in some a combination of sutures, adhesive plaster, 
and compress is necessary/' 

No one would, of course, pass stitches through the muscular substance. 

The majority of French surgeons have always opposed union by the first 
intention. Even Larrey, during a career of more than half a century, always 
opposed it, but some of the modern French surgeons are in favour of the 
practice. 

Anaesthetic Agents in Operations for Gunshot Wounds. — In our former 
paper, the case of Williamson was presented with some remarks in relation to 
the use ofipsulphuric ether for producing anaesthesia in operations in the Gene- 
ral Hospital at Vera Cruz, in 1847. In the summer of that year, an amputa- 
tion of the thigh was performed, the patient having been put under the 
influence of ether, in which the hemorrhage was almost uncontrollable. The 
blood spouted in all directions, and I have never seen an operation where it 
was necessary to secure so many bleeding vessels. Even after every small 
vessel that could be got at was secured, it was necessary to use cold water 
freely to suppress the general oozing of blood. At the time, I imputed the 
obstinate hemorrhage to the pernicious influence of the ether. In gunshot 
wounds anaesthetic agents are almost universally unnecessary, and are almost 
universally injurious. It was for this reason that they were entirely given 
up in the hospital at Vera Cruz. 

It may be well questioned whether anaesthetics are not calculated to pro- 
duce injurious effects in all important amputations; but they certainly do so 
in operations performed for gunshot wounds. M. Yelpeau says : " Chloroform 
evidently depresses the nervous system, and as great prostration always exists 
in patients who have received gunshot wounds, it is advisable to refrain from 
any anaesthetic means/' — Ranking' s Abstract, 1848. Mr. Alcock refers to 
the cases of soldiers wounded in battle, where the excitement is such as to 
carry them through almost any operation. I regret that Mr. Alcock' s paper 
is not before me. These are the cases spoken of by Mr. Guthrie : " Soldiers 
in general are anxious to undergo an operation when they find it inevitable, 
and frequently press it before the proper time ; that is, before they have suffi- 
ciently recovered the shock of the injury." — Gunshot Wounds, p. 232. These 
are the cases which require a little more time, some " encouraging words," 
and perhaps a little wine or brandy and water; but no anaesthetics, for the 
patients are already sufficiently depressed. 

There are two sets of cases ; in the one (Yelpeau' s), the shock to the nerv- 
ous system is great, from which the patient may not recover, and the use of 
anaesthetics would be awfully destructive ; in the other class, they are unneces- 
sary, and would prove useless and injurious. In the flap operation, they must 
No. XLVIL— July, 1852. 3 



so 



Porter, Surgical Notes of the Mexican War. 



prove more injurious than in the circular; from the fact that muscle forms 
almost the entire covering for the stump ; and the contractility of the muscu- 
lar tissue is for a time almost annihilated, to be recovered irregularly at irre- 
gular intervals. Further, after the use of these agents wounds do not heal so 
readily by the first intention. 

M. Jobert, on the use of ether, states that the local inflammation has proved 
less, and that union by the first intention has been prevented. I am able to 
bear testimony to the correctness of M. Jobert' s statement. 

I must be permitted to refer to the Transactions of the American Medical 
Association for 1851, pp. 271, 272, 315, 323. In the Massachusetts Gene- 
ral Hospital : — 

" It does not appear that the fatal results of amputation have at all dimin- 
ished by the introduction of anaesthetic agents." 

New York Hospital : — 

"The general mortality has been for three years and a quarter forty per 
centum. As regards the method of operating, we observe that the amputations 
of the thigh, in which the fatality was as high as thirteen in seventeen, were all 
flap operations. Eleven of the leg were removed by the circular, one died ; 
while of four by the flap, two died." 

That is, nine per cent, in one set of cases, and fifty per cent, in the other. 

"In almost every case chloroform or ether was employed; but, while it is 
admitted that anaesthetics may have had some influence in the increased mor- 
tality in the New York Hospital over preceding years, since union by the first 
intention was now much less frequently observed ; still it is to be remembered 
that hospital gangrene, entirely unknown before, and purulent cachexia and 
erysipelas extensively prevailed there during the past three years." 

Could the anaesthetics have had an influence in producing the " hospital 
gangrene, entirely unknown before," and the " purulent cachexia and erysi- 
pelas," as well as prevent union by the first intention ? 

Dr. Lente, Resident Surgeon of the New York Hospital, says : — 

" In almost every case, however, either chloroform or ether was employed ; 
generally the former until the occurrence of a fatal case from it in this hospital ; 
afterwards the latter, from which we have never had any bad consequences, and 
which has never failed to prove effectual. * * * Anaesthetics came into gene- 
ral use about the period of the commencement of these statistics. May not 
the employment of these have had its influence upon the mortality ? This is 
a very important question. We do not deny that it may have had some influ- 
ence in augmenting the fatality of operations ; but we have seen no reason to 
infer that it has, except perhaps the fact that union by adhesion seems to have 
been much less frequent since the introduction of anaesthetics into this hospi- 
tal than before. Whether the two are in the relation of cause and effect, it is, 
we fear, impossible to determine at present." 

In an unhealthy atmosphere or climate, the healing of wounds by adhesive 

union is doubly important for obvious reasons; and I have often regretted 

that etherization was so much resorted to in capital operations at Vera Cruz 

during a portion of 1847; nor can I avoid congratulating both the patients 

and myself that, before the summer had passed away, its employment was 

wholly abandoned. Anaesthetics poison the blood and depress the nervous 

system; and, in consequence, hemorrhage is much more apt to occur, and 

union by adhesion is prevented. 



1852.] 



Clarke ; Contributions to Aural Surgery. 



31 



Art. II. — Contributions to Aural Surgery. — Analysis of One Hundred and 
Forty Cases of Diseases of the Ear. By Edward H. Clarke, M. D., 
Boston, Mass. 

M. Itard, in the preface to his treatise upon diseases of the ear and 
audition, written thirty years ago, stated that a careful exposition and rational 
therapeutics of diseases of the ear were then to be written. At the close of 
the same paragraph, he says : " Certain vague or antiquated ideas with regard 
to the relaxation and tension of the membrane of the tympanum, to pretended 
abscesses of the ear, paralysis of the acoustic nerve, and the occlusion of the 
Eustachian tube, form nearly the whole theory of deafness; just as the vulgar 
application of blisters, the instillation of sundry insignificant liquids into the 
external ear, and the empirical perforation of the membrane of the tympanum, 
compose the entire therapeutics of these diseases."* Martell Frank, writing 
twenty-five years later than Itard, commences his late work upon the Diag- 
nosis and Treatment of Diseases of the Ear with very similar language. 
" There is scarcely a specialty," he says, u of exact medical science and art 
upon which the attention of physicians has hitherto been less bestowed than 
upon diseases of the ear."f The reproaches of Itard, more than a quarter of 
a century ago, and of Frank, at the present day, are unfortunately too true. 
Of late years, however, there has been much improvement with regard to the 
study of aural diseases; and, consequently, with regard to their treatment. 
They are no longer neglected by the profession, and taken up solely by em- 
pirics. There are many careful observers, particularly in England and on 
the continent of Europe, who are directing their attention to the ear and its 
diseases ; and through their labours we may hope that hereafter aural surgery 
will rest, or rather be built up, upon what can form the only true basis of 
any science, that of well-observed and carefully recorded phenomena. 

It is with the hope of contributing something towards a more accurate 
knowledge of the diseases of the ear in this country, that the record of the 
following cases is offered to the attention of those who are interested in this 
limited, but not unimportant, branch of surgery. 

The examination of all the cases which are presented in this paper was 
made, almost without exception, in a clear sunlight, assisted by Meniere's 
speculum auris, and, when necessary, by the use of the Eustachian catheter 
and the auriscope. The latter instrument, or, as it is sometimes called, the 
otoscope, is of great assistance in examinations of the ear, and especially 
in examinations of the Eustachian tube and the cavity of the tympanum. It 

* Traite des Maladies de TOreiUe et de l'Audition, par J. M. G. Itard, Paris, 1822, 
p. v. 

| Practiscbe Anleitung zur Erkermtniss and Behandlung der Ohrenkrankbeiten, von 
Dr. Martell Frank, 1S45, Vorrede. 



32 Clarke, Contributions to Aural Surgery. [July? 

frequently obviates the necessity of catheterizing the Eustachian passages, 
and thus facilitates an examination, both for the physician and patient. The 
records were made either at the time of the examination, or immediately 
after, and no cases are included which were not carefully recorded. No 
attempt has been made at a selection of cases. They are recorded as they 
were presented for treatment. Quite a number which might have been in- 
cluded in the analysis are not, on account of some imperfection in the record. 
Probably an equal proportion, however, of each class of diseases of the ear 
has been omitted. Those which are included, therefore, may be considered 
as representing, with a tolerable approximation to accuracy, the varieties of 
aural disease as they occur in New England, and the proportion of each class 
to the others. 

The classification which I have adopted is that proposed by Kramer, and 
sanctioned by Meniere. It is, perhaps, the most convenient for practical use 
of any that has been proposed ; though liable to the charge of not being 
really scientific. According to this classification, diseases of the ear are divided 
into those of the external ear, of the membrana tympani, of the middle ear, 
and of the internal ear. T^e diseases of these different classes are so apt to 
run into each other, that it is not always an easy matter to separate them 
accurately in practice, and to assign to each one its proper position. This is 
particularly true of the first three classes; and the difficulty is increased by 
the fact that, in a great majority of instances, no application is made for 
relief until the disease has made considerable progress, and extended beyond 
its original seat. A careful inquiry into the history of the case, together with 
an accurate examination of the diseased parts, will, in most cases, however, 
enable the practitioner to distinguish with sufficient accuracy affections of one 
class from those of another. Otorrhceas, following the exanthemata, in which 
not only the membrana tympani is diseased, but frequently also the dermal 
tissue of the meatus and the cavity of the tympanum, are classified under the 
head of diseases of the membrana tympani. When the discharge has pro- 
ceeded from the meatus, without involving the fibrous coat of the membrane 
of the tympanum, even if the external coat of this membrane were implicated, 
the disease has been classed with affections of the external ear. In this way 
I have endeavoured to trace every discharge to its seat, and classify it accord- 
ingly. To make a distinct class of diseases, called otorrhceas, would be to 
substitute a symptom for its cause. In like manner, polypous and fungoid 
growths are classed according to their seat, as an attendant of some other 
affection, and not separated into a distinct class. 

One of the most practical questions with regard to diseases of the ear con- 
cerns their curability. Many persons, both within the profession and out of 
it, are incredulous as to the advantage of treating aural diseases. The follow- 
ing are the results, bearing upon this point, obtained from 140 cases : — 



1852.] Clarke, Contributions to Aural Surgery. 33 



Table of the Curability of Diseases of the Ear. 



Name of the disease. 


Re- 


Im- 


Not im- 


Not 


Total. 




lieved. 


proved . 


proved. 


treated. 




Extekxal Ear. 












Acute inflammation of the dermal tissue of 






















4 


Chronic inflammation of the dermal tissue 














3 








4 


Acute inflammation of the cellular tissue 














5 








5 


Acute inflammation of the glandular tissue 














1 








1 


Chronic inflammation of the glandular 














1 








1 




- i' v 








1 




16 








16 


Memuraita Tympani. 














7 








7 


Chronic myringitis, not succeeding scarla- 














5 


6 


3 


6 


20 


Chronic myringitis, succeeding scarlatina 


5 


12 




5 


22 


Middle Ear. 












Acute catarrh of the middle ear .... 


6 








6 


Chronic catarrh of the middle ear . 


5 


4 






9 


Acute inflammation of the deep-seated 














2 


1 






3 


Chronic catarrh and obstruction of the Eus- 



















1 




1 


IjfTERjTAT. Ear. 
















7 


10 


17 


34 










4 


4 




1 






1 


2 


Total 


62 


31 


14 


33 


140 



Omitting the different varieties of each class, this table presents the follow- 
ing result : — 





Total 


Re- 


Im- 


Not im- 


Not 




No. 


lieved. 


proved. 


proved. 


treated. 




32 


31 


1 








Affections of the membrana tympani . . 


49 


17 


18 


3 


11 




19 


13 


5 


1 






40 


1 


7 


10 


22 


Total 


140 


62 


31 


14 


33 



From this it appears that nearly all the diseases of the external ear, or 
more than 0.9, were relieved. Such favourable results were not obtained in 
diseases of the membrana tympani. Out of 49 cases of disease of this mem- 
brane, only 17, or about 0.35, were relieved; 18, or 0.37, were improved; 
and 14, or 0.28, were incurable. Diseases of the middle ear proved to be 
more amenable to treatment. Out of 19 cases, 13, or about 0.68, were re- 



34 



Clarke, Contributions to Aural Surgery. 



lieved; 5, or 0.26, were improved; and 1, or 0.05, were incurable. Diseases 
of the internal ear were the most intractable of all. Only 1 out of 40 cases, 
or not quite 0.03, were relieved; 7, or nearly 0.2, were improved; and 32, 
or 0.8, were incurable. The aggregate result is this: 62 from 140 cases of 
disease of the ear, or 0.44, were relieved; 31, or 0.22, were improved; and 
47, or 0.33, were found to be incurable. In other words, about two-thirds of 
these cases were improved or relieved by treatment, and the remaining third 
were incurable. This result, though not so favourable as might be wished, 
is by no means a discouraging one. It shows that something may be done 
for the relief of these complaints; and, doubtless, more would be accomplished, 
if greater attention were bestowed upon them. Almost all the above cases of 
disease of the external ear proved to be susceptible of relief ; next came those 
of the middle ear ; then those of the membrana tympani ; while scarcely two- 
tenths of those of the internal ear (nervous deafness) were even improved. 

So far as the external ear, the membrana tympani, and the middle ear are 
concerned, this result agrees very nearly with the statistics of Kramer. It 
does not accord so well, however, with the results he obtained in treating 
diseases of the internal ear. According to his statement, out of 2000 cases, 
1568, or about 0.8 (rather more than two-thirds) were either improved or 
relieved; while 382, or less than 0.1, were incurable.* In affections of the 
external ear, 276 out of 286, or 0.9, were relieved; 6 were improved; and 4 
were incurable. In diseases of the membrana tympani, 72 out of 442, or 
nearly 0.2, were relieved; 325, or 0.7, were improved; and only 45, or 0.1, 
were found to be incurable. That is, nine-tenths were either relieved or im- 
proved, and only one-tenth were incurable. From my own statistics, it ap- 
pears that not quite eight-tenths were relieved and improved, and rather more 
than two-tenths were incurable. Again, with regard to the middle ear, M. 
Kramer obtained a cure in 166 cases out of 198, or a proportion of more 
than 0.8; 16, or 0.08, were improved; and the same number were incurable. 
This agrees very nearly with the proportions obtained from my own much 
more limited number of cases. With regard to the internal ear, there is con- 
siderable disparity. Out of 1074 cases of nervous deafness, treated by M. 
Kramer, 54, or 0.05, were relieved; 703, or nearly 0.7 were improved; and 
317, or only about 0.4 were incurable. Of the 40 cases of nervous deafness 
reported above, 32, or eight-tenths are given as incurable. It should be 
stated, however, in this connection, that I declined to treat 22 of the 40 cases 
at all ; and but very few of the remaining 18 were treated for the length of 
time (three months or more) which Kramer considers necessary in order to 
produce any beneficial change in affections of the acoustic nerve. 

One reason why diseases of the ear are so often treated unsuccessfully is 
the length of time which patients allow to elapse after the disease has com- 

* Traite des Maladies de TOreille, par Guill. Kramer, traduit de 1'Allemand par P. 
Meniere, p. 66. 



1852.] 



Clarke, Contributions to Aural Surgery. 



85 



menced before it is submitted to treatment. There appears to be a great 
unwillingness in the community to have their ears " meddled with," as the 
phrase is. In many cases, weeks, and months, and years are allowed to pass 
by, after the hearing is affected, before any attempt is made to obtain relief. 
In consequence of this delay, organic changes often occur, which are irre- 
mediable, and which might have been prevented. Moreover, diseases of the 
ear, even affections of the meatus as well as of the membrana tympani and 
middle ear, and particularly those of the internal ear, are out of sight; they 
are not obvious, like many affections of the eye. The attention of the patient 
is not drawn to the ear, as being really the seat of any trouble, because he 
cannot see any redness or other disturbance. He may be sensible of occa- 
sional irritation, or pain, with or without tinnitus, and accompanied with more 
or less deafness. All this is regarded as a temporary matter, which will soon 
pass away ; and thus the disease is allowed to go insidiously on, unchecked. 
If the various forms of inflammation, which attack the external auditory 
meatus and the membrana tympani, were as visible and as easily recognized 
as those which occur in the eye, the former would doubtless be as promptly 
attended to as the latter. The following table exhibits a striking confirmation 
of the above remark : — 



Table of the Time elapsed before Application for Relief 





External 


Membrana 


Middle 


Internal 


Total. 




ear. 


tympani. 


ear. 


ear. 




Two weeks and less 


4 


5 


4 




13 


Three to four weeks 


< X : 


3 






13 


One to twelve months 


3 


8 


3 


4 


18 


One to five years 


2 


11 


4 


15 


32 


Above five years 




22 


5 


21 


48 


Unknown (accumulation of wax) 










16 


Total 










140 



From this it appears that only 13 (out of 140 individuals whose ears were 
diseased) applied for relief within two weeks from the supposed commence- 
ment of the attack, while 80 suffered more than a year to elapse, and 48 more 
than five years to elapse, before seeking medical aid. I cannot doubt that 
many of these cases might have been relieved if they had been treated early. 
A prompt attention to any disturbance in the ear is particularly important in 
inflammations of the membrana tympani. Acute myringitis is generally 
amenable to treatment, while chronic myringitis, whether resulting in thick- 
ening or in perforation of the membrane of the tympanum, is one of the most 
irremediable forms of aural disease. 

The etiology of diseases of the ear is exceedingly obscure. Individuals, 
whose audition is in any way impaired, are not usually seen by competent 
observers until the disease is fully established. And even when the cause is 
well ascertained, as in otorrhcea and the like following scarlatina or the other 



86 



Clarke, Contributions to Aural Surgery. [July 



exanthemata, we know very little of the modus operandi of the cause ; we do 
not know what the destructive processes are to which the tissues of the ear 
have been subjected. Thus far I have met with but very little that is satis- 
factory on this point. The following tables embody the few results at which 
I have arrived : — 



Influence of Sex and Age on Diseases of the Ear. 





Male. 


Female. 


Under 10. 


10 to 20. 


20 to 30. 


30 to 40. 


40 to 50. 


50 to 60. 


External ear 


20 


12 


5 


9 


10 


3 


4 


1 


Membrarm tympani 


23 


26 


19 


10 


9 


5 


4 


2 


Middle ear 


8 


11 


1 


9 


7 


2 






Internal ear 


23 


17 


3 


4 


11 


12 




7 


Total 


74 


66 


28 


32 


37 


22 


11 


10 



Difference of sex does not appear to exert any great influence upon diseases 
of the ear. There were eight more males than females, according to the 
above tables, whose ears were more or less affected, out of 140 cases. It 
is very possible that even this difference was accidental. At any rate, it is not 
marked enough to warrant the conclusion that the male sex are more liable 
than the female to these diseases. This is not the case, however, with regard 
to age. Infancy and childhood are especially liable to certain classes of dis- 
ease ; manhood and age to other varieties. Thus it appears that 14 out of 32 
cases of disease of the external ear, or nearly one-half, occurred under the 
age of 20; and 5 of these under the age of 10. More than one-half of the 
affections of the membrana tympani, or 29 out of 49 cases, occurred under 
20 ; and 19, or very nearly one-half, under 10. Again, with regard to the 
middle ear, 9 out of 19 occurred between the ages of 10 and 20. When we 
come to the internal ear, the case is reversed. Only 7 out of 40 cases of 
nervous deafness occurred under 20; and of these 7, 3 were probably con- 
genital ; while 22, or more than one-half of the individuals affected, were 
above 30 years of age, and 10 were above 40. The largest number of diseases 
of the external ear occurred in individuals between 10 and 20 ; of the mem- 
brana tympani, in those under 10 ; of the middle ear, in those between 10 
and 20; and of the internal ear, in those from 30 to 40. The general result 
of these figures goes to show that infancy and childhood are peculiarly 
exposed to affections of the external auditory meatus and of the membrana 
tympani; individuals from 10 to 30 to affections of the middle ear, including, 
of course, the Eustachian tube, and often implicating the fauces ; and that 
after 30 the internal ear is most frequently affected. 

The following table presents a view of various other circumstances that 
appeared to have exerted a marked influence in causing the diseases recorded 
above : — 



1852.] Clarke, Contributions to Aural Surgery. 37 



Causes of Diseases of the Ear. 











Succeedin 










Diseases of the 




Cold. 


Scarla- 


Measles. 


j. } pnoiu 


Acci- 


Epilep- 


Here- 


Syphi- 


^ 

Un- 






tina. 




fever. 


dent. 


sy. 


ditary. 


lis. 


known . 


External ear 


13 


1 















14 


Membrana 




















tytnpani 


9 


22 




1 


3 




2 


1 


11 


Middle ear 


11 
















S 


Internal ear 






i 




1 


1 


17 




16 


Total 


33 


23 


5 


5 


4 


1 


19 


1 


49 



It will be seen from this, that cold holds the most prominent place as a 
cause of disturbance in the ear. 33 out of 140, or 0.23 per cent, of all the 
above cases, followed exposure to cold. This confirms the remark of M. 
Kranier, that "cold, in whatever form it reaches the ear, acts in a most inju- 
rious manner upon the acoustic nerves, and upon all the constituent parts of 
the auditory apparatus."* The exanthemata stand next in frequency to cold 
as a cause of disease. In the cases which have been presented to my obser- 
vation, scarlatina has been much more frequently followed by otorrhcea or 
some other affec-tion, than measles. Whether a more extended observation 
would confirm this remark is perhaps doubtful. Of the 23 cases of aural 
disease which followed scarlatina, 22 are recorded under the head of disease 
of the membrana tympani. It is possible that, in some of these instances, the 
affection had its origin either in the middle ear or in the external meatus ; 
but, as in all of them, the membrane of the tympanum was the part most 
seriously disorganized, they are classed under that head. Hereditary predis- 
position does not appear to be a very efficient cause, except in affections of the 
internal ear. In 17 out of 40 cases of nervous deafness, or nearly one-half, 
the disease seemed to be in a greater or less degree inherited. So far as these 
cases go, it is fair to infer that hereditary predisposition exerts a powerful 
influence in producing the most incurable kind of deafness, viz., that resulting 
from some disease of the acoustic nerve \ and but very little influence in pro- 
ducing any other. Next to hereditary predisposition, typhoid fever is recorded 
as the most active agent in causing nervous deafness ; or, perhaps, I should 
say, the most frequent antecedent to this affection. Only 4 cases, however, 
or not quite 0.1, were thus originated. For a large number of cases no cause 
could be ascertained, though careful inquiries were always instituted. We 
should not infer from this that in all these instances the disease originated 
spontaneously. Owing to forgetfulness, or lack of intelligence, or of obser- 
vation on the part of the patients or their attendants, it was often impossible 
to ascertain the circumstances under which the affection arose. In no other 
organ of special sense is the commencement of disease more liable to be over- 



Op. cit., p. 27. 



ss 



Clarke, Contributions to Aural Surgery. 



looked than in the ear. It appears, then, from these observations, that the 
following circumstances may be considered as influential causes of aural 
disease, viz., cold, the exanthemata, hereditary predisposition, and typhoid 
fever. 

The duration of treatment varies considerably for the different varieties of 
disease. Thus, of 32 cases of disease of the external ear, 16 were accumula- 
tions of wax, and were relieved at once. Of the remaining 16, 3 were 
relieved after a treatment of from one to two weeks; 7 after a treatment of 
from two to three weeks ; 4 were treated from one to two months ; and the 
remaining 2 from two to three months. Diseases of the membrana tympani 
were not so readily relieved. Of 49 cases, 11 were not treated. Of the remain- 
ing 38, only 7 were treated less than a month, and these were cases of acute 
myringitis; 26 were treated for a period of from one to six months; and 5 
from six to twelve months. It should be recollected, however, that a large 
proportion of these were cases of otorrhoea, whose inveteracy is well known 
to all who are at all acquainted with aural diseases. Of 19 cases of disease 
of the middle ear, of which 18 were either relieved or improved, 5 were 
treated from one to four weeks; 13 from one to four months; and 1 from 
eleven to twelve months. 40 cases are given above of diseases of the internal 
ear. Of these, 22 were not treated. Of the remainder, 3 were treated for 
less than a month only; 7, from one to two months; and 7 from two to five 
months. It appears from this, that affections of the external auditory meatus 
are relieved after a comparatively short treatment. Those of the membrana 
tympani, when acute in their character, are equally amenable to treatment; 
but, when chronic, are among the most inveterate of aural diseases. Those 
of the middle ear are frequently chronic in their character, and often require 
considerable patience, both from the practitioner and patient, in order to arrive 
at a satisfactory result. Lastly, affections of the internal ear, unless they are 
merely symptomatic of some more general affection, and, therefore, relieved 
when that affection is relieved, are either incurable, or, according to Kramer, 
require a treatment which shall continue, not for weeks, but for several months. 

There are several other points of interest which we have not space to dwell 
upon, but which are presented by the following table. They are the con- 
dition of the ceruminous secretion in the various affections mentioned above, 
the absence or presence of otorrhoea, perforations of the membrana tympani, 
polypous and fungoid growths, complications, and the like. 



1852.] 



Clarke, Contributions to Aural Surgery. 



89 



Names of the disease. 


j Wax absent. 


Do. deficient. 


Do. normal. 


Do. in- 
creased. 


si ? 

~ 8 
>^ 


1 With poly- 


pus or fun- 
gus. 


Membrana 

tympani 

normal. 


Do. more or 
less opaque. 


I Do. perfo- 
1 rated. 


Fauces 
i diseased. ! 


1 Tonsils 
1 enlarged. 


Cervical 
glands en- 
larged . 


External Ear. 




























Inflammation of dermal tis- 




























sue of meatus ; acute, 




























chronic, and eczematous 


3 


4 


2 




9 




3 


4 


1 




2 


2 


4 


Inflammation of cellular 




























tissue of meatus ; acute . 


3 


2 






5 






4 












Inflammation of glandular 




























tissue; acute and chronic 


2 








2 




1 










1 




Accumulations of Avax . 








16 








16 












Membrana Tympani. 




























Myringitis; acute 


1 


3 


2 


1 


1 








1 


3 


2 


1 


1 


Myringitis ; chronic . 


8 


10 


2 




10 




5 




9 


11 


5 


7 


7 


Myringitis following scar- 




















22 










7 


n 


4 




22 




6 






6 


9 


6 


Middle Ear. 




























Acute catarrh of middle ear 




4 


2 
















5 


3 


1 


Chronic catarrh of middle 






























2 


5 


3 
















8 


5 


2 


Inflammation of deep-seated 
























1 




tissues of middle ear . . 


2 


1 






3 




2 






3 


3 


1 


Internal Ear. 




























Nervous deafness not con- 






























1 


23 


10 










20 


14 




5 


4 


4 


Nervous deafness congeni- 
































1 


3 










4 








2 


2 


Symptomatic deafness . . 






2 










2 














29 


IT 


30 


17 


52 


17 


50 


25 


39 


36 


35 


28 



The condition of the cemminous secretion is generally considered to be of 
great importance as a symptom in diseases of the ear. A glance at the above 
table will show that the cerumen of the ear was subject to greater or less 
changes in all these diseases. In 16 cases of the disease of the external 
ear, it was increased in quantity; in 14 out of the other 16 cases, it was either 
deficient or absent. In 40 out of 49 cases of disease of the membrana tym- 
pani, and in 14 out of 19 of the middle ear, it was likewise either absent 
or deficient. Out of 40 cases of nervous deafness, the cerumen was healthy 
in only 15; deficient in 24; and absent in 1. Some writers have stated that 
an absence or deficiency of cerumen is an indication of nervous deafness. 
The results which are exhibited above do not confirm this statement. They 
rather go to show that any deficiency of cerumen is more an indication that 
the auditory apparatus is in some way diseased, than a symptom of any par- 
ticular affection. 

The above table shows conclusively the impropriety of establishing a sepa- 
rate class of diseases, called otorrhoea. It will be seen, by a simple inspec- 
tion of the table, that a discharge from the ear accompanied inflammation of 
the dermal, glandular, and cellular tissues of the meatus of the membrana 
tympani, and even of the middle ear. In fact, a running from the ear, as it 
is popularly termed, is a circumstance of frequent occurrence in diseases that 
are essentially different; as different as simple inflammation of the dermal 
tissue of the meatus, chronic inflammation of the membrane of the tyin- 



40 



Clarke ; Contributions to Aural Surgery. 



panum, and acute inflammation of the deep-seated tissues of the cavity of 
that membrane. 

Fungoid growths, polypus, and the like, seem, like otorrhcea, to be asso- 
ciated with very different affections. It would be interesting to examine 
their different varieties, manner of growth, position in different parts of the 
meatus, and other circumstances ; but the extent which this paper has already 
reached forbids such an investigation. It appears that 17 instances of such 
growths occurred in 140 cases of disease of the ear; and 15 out of the 17 
instances accompanied affections of the external auditory meatus and of the 
membrana tympani. 

One of the most frequent and unfortunate results of inflammation of the 
membrana tympani is perforation of that membrane. This occurred in 36 
out of 49 cases, presented above. Three of them followed acute, and the 
remainder chronic myringitis. The same membrane was also perforated in 
the three instances which are given of inflammation of the cellular tissue of 
the middle ear, or, as it is sometimes called, internal otitis. The three in- 
stances of perforation with acute myringitis were healed, and the membrane 
restored to its normal condition. The same took place in two out of the three 
cases of inflammation of the middle ear. There are 33 cases presented 
of perforation occurring with chronic myringitis. In only two of these was 
the perforation healed; and in that form of myringitis following scarlatina 
no instance of restoration of the membrane occurred. In many of these 
instances, there can be no doubt that a neglect of proper treatment — an 
unwillingness on the part of the patient, or the patient's friends, to have the 
discharge interfered with — contributed very considerably to this unfortunate 
result. Opacity of the membrana tympani is another and a not unfrequent 
result of chronic myringitis. When it is produced by the deposition of lymph 
between the layers of the membrane, it is almost irremediable. The record 
shows 20 cases of this variety of inflammation not resulting from scarlatina. 
In 9 of these cases, that is, nearly in one-half of them, opacity occurred to a 
greater or less degree. In 26 cases of nervous deafness, the membrane of 
the tympanum preserved its normal appearance; in 14 cases, it is stated to 
have been more or less opaque. The opacity, however, in these cases had not 
the milky appearance, resembling the conjunctiva, which is seen in chronic 
myringitis, but was rather a dulness — an apparent want of vitality in the 
membrane, a dead look — than actual opacity. 

Inflammation of the fauces and the neighbouring parts is a frequent com- 
plication of diseases of the ear. It appears above that 36 instances of this 
complication existed in 140 cases. In other words, we may infer that in 
more than one-fourth of the diseases of the ear, occurring in New England, 
some affection of the fauces or nasal passages probably exists. Indeed, the 
frequent occurrence of deafness with colds is a matter of ordinary observa- 
tion. In 35 cases, the fauces were not only diseased, but the tonsils were 
enlarged. 



1852.] 



Eve, Gases of Urinary Calculus. 



41 



A strumous diathesis has often been insisted upon by aurists, and especially 
by Schmalz, as a predisposing cause to disease of the ear. So far as it is 
proper to generalize from 140 cases, the statistics we have given go to confirm 
this notion. For it appears from the preceding table that, in 35 out of the 
140 cases — that is, in 25 per cent, of them — there were enlarged cervical 
glands as well as enlarged tonsils. And it should be noticed that enlarge- 
ment of the tonsils and glands of the neck occurred more frequently with 
affections of the middle ear and membrana tympani than with any other class. 

We have now completed this analysis, so far as our limits will allow. 
We have omitted several points to which we should have been glad to 
direct attention, and dwelt, perhaps, too briefly upon others. It was our 
intention to add something upon the course of treatment which was pur- 
sued in the cases which have been presented ; but we do not feel that it is 
proper, at the present time, to trespass farther upon the patience of our 
readers. 



Art. III. — Report of Twenty-five Cases of Urinary Calculus, in Twenty- 
three of which the Bi-lateral Operation was performed. By Paul F. Eve, 
M. D., Professor of Surgery in the Nashville University, Tennessee. 

Among the committees appointed at the last meeting of the American 
Medical Association, was one to collect the statistics of the operation for the 
removal of stone in the bladder. In October, 1841, I first performed litho- 
tomy ; since then, a period of eleven and a half years, I have operated tfpon 
twenty-four cases of urinary calculus; nine of them within twelve months, four 
in Georgia and five in Tennessee. No one will doubt the importance of 
carefully prepared surgical statistics ; and to make mine the more full and 
authentic, the valuable assistance of Prof. Means and Dr. Barry in the che- 
mical analysis, and of Dr. Juriah Harris with the microscope, has been 
invoked in the examination of my collection of vesical stones, amounting to 
about one hundred and forty. In the analytical investigation, all proposed 
was simply the qualitative and not the quantitative composition of these 
foreign bodies. 

The cases are now narrated in the order of their occurrence : — 

Case I. — A mulatto boy, eight years old, coming from Lincoln County, 
Georgia, has had symptoms of stone for some indefinite period. The bi-lateral 
operation was performed on him in October, 1841, after the method of 
Dupuytren, with the double lithotome cache. A mulberry calculus, weighing- 
two drachms, was extracted. This is the handsomest specimen of the oxalate 
of lime formation in my collection. The mulberry-like granulations are small, 
distinct, and perfect. The wound healed so kindly that on the fourth day 
after the operation, the patient was considered well ; in fact, was out of hi3 
room. 



42 



Eve, Cases of Urinary Calculus. 



This is believed to have been the first time lithotomy was performed in 
Augusta. So late as 1845, this operation had never been required in Sa- 
vannah, and had not then been performed a dozen times even in Charleston. 
Up to the present time, I believe I have cut for stone oftener than all the 
professional gentlemen that ever lived in these three great southern cities, 
Augusta, Savannah, and Charleston; so unfrequent are calculous cases in 
this section of our country. 

Case II. — Master H was six years old, resided in Baldwin County, 

Georgia. Irregularity in urinating was observed at twelve months of age, 
and attributed by his mother to a needle introduced into the urethra, which 
she thought had passed into the bladder. The bi-lateral operation was per- 
formed in May, 1843, and a large stone removed. It was light compared to 
its size, weighed about four drachms, and is the ammoniaco-magnesian phos- 
phate. This patient had a speedy recovery, having been up and about the 
room on the fifth day after the operation. 

Case III. — A mulatto boy named Lewis, three years old, labouring under 
symptoms of stone for several months, was cut with the double lithotome in 
June, 1843. A calculus of the mulberry variety, weighing a drachm and a 
half, was extracted. This patient sat up on the fourth, and was well on the 
eighth day after the operation. 

From inquiry specially directed to the subject at the time, this is supposed 
to be the second case of stone known to have originated in Augusta. The 
first was taken to New York, several years ago, and operated upon by Dr. 
Mott. 

Case IY. — This patient, aged three years, who also resided in this city, was 

the son of Mr. S . He was operated upon in October, 1845, by the bi-lateral 

method ; a calculus, measuring two and three-quarters inches in its longitudinal 
circumference, was removed; and the patient had a speedy recovery. The 
composition of the deposit in this case is the ammoniaco-magnesian phosphate. 
There was some hemorrhage during the operation, but fortunately no recur- 
rence after it. 

Case Y. — In this instance the stone was removed by crushing during the 

months of November and December, 1845. Mr. L , aged thirty-four, 

came from Early County, Georgia. The calculus measured in diameter over 
an inch, and was broken up in eighteen sittings by Charriere's make of 
Heurteloup's instrument. The patient was not confined even to his room 
during the treatment, suffered no acute pain, passed no blood, and up to 
the present date continues well. A fragment which seemed to be the 
outer layer of the calculus, yielded to chemical reagents, phosphate of lime ; 
but from the resistance offered the lithotriptor, and the physical appearance 
of other pieces passed per urethram, I am inclined to think the central mass 
to have been the oxalate. 

The account of this case, with a notice of the operation of lithotrity and 
lithotripsy performed in the United States, was published in the Southern 
Medical and Surgical Journal for February, 1846. 



1852.] 



Eve, Cases of Urinary Calculus. 



43 



Case VI. — A negro woman, aged twenty-four ; married and has borne one 
child, came from Alabama, and was cut in January, 1846. The calculous 
formation in this case was evidently the result of an injury to the bladder. 
Four years before her arrival here, she fell astride a projecting bar, and sus- 
tained, no doubt, a fracture of the pelvis. There was great contusion of the 
external organs of generation ; the patient was confined six months to bed, 
unable to walk ; and for a year could not labour. Great difficulty was expe- 
rienced in micturition, little urine could be retained, and for four months 
the catamenia had failed. An inch and a half behind the orifice of the 
urethra, a small object was felt projecting into the vagina, and the sound 
instantly detected a foreign body in the bladder, apparently filling it. 

A vesico-vaginal fistula already existing, in operating, the urethra was laid 
open to it, and a piece of bone, coated with uric acid, was removed. This was 
the foreign body which had ulcerated through the bladder into the vagina ; 
was of an irregular shape, and about three-fourths of an inch square. A 
large, soft, calculous mass felt in the bladder was now scooped out, and then 
its nucleus, another and larger piece of bone, was seized, but could only be 
extracted after a second incision made in the soft parts towards the clitoris, 
and by repeated efforts. Nor was the bladder even yet emptied of foreign 
matter, for during the treatment, a calculous mass, weighing forty-five grains, 
was passed through the wound. 

The duration of this operation was about an hour, and left the patient 
quite exhausted. Incontinence of urine, so much to be apprehended after 
lithotomy in the female, was certainly expected. This, however, she has not 
only escaped, but has been restored a useful servant to her owner. 

The composition of the calculus was uric acid ; the nuclei, when sawed in 
two, presented the cancellated structure of bone, and were reduced by reagents 
to animal matter and phosphate of lime. 

Remarks. — In reference to the result of incontinence of urine after litho- 
tomy in women, we think a difference will be observed dependent upon the 
age of the patient. In children this deplorable event will, we think, be found 
pretty uniformly to follow the operation, while the adult female may escape. 
This is just what might be expected from the relative development of the 
organs interested in its performance. We have received the particulars of a 
case in which the urethra and vagina were freely incised in childhood ; this 
patient lived to become a young lady, but was ever an object of disgust to 
herself and of pity to her friends; death happily relieved her condition, made 
worse by lithotomy. One of our pupils, Dr. Groce, of Alabama, has pub- 
lished the case of a married lady, in which he cut immediately upon the stone 
through the vagina and urethra, and after removing it, was, to his great surprise, 
on being summoned to the same patient, eight days afterwards, called upon to 
re-open the wound for the purpose of extracting a second calculus; and yet 
she fully recovered, bore a child, and enjoyed unusual health. And in the 
case suggesting these remarks, the recovery has been equally good, notwith- 
standing the free incisions made into the soft parts under very unfavourable 
circumstances. 

Case VII. — Dr. II , when about twenty years old, and living then in 

Henry County, Georgia, was relieved by lithotomy, in April, 1847. He had 



44 



Eve, Cases of Urinary Calculus. 



laboured under symptoms of stone for several years. The operation was the 
hi-lateral. The patient refused to inhale ether or to submit to the continuance 
of the operation after it was commenced. It was nevertheless performed, and 
a small oxalate of lime calculus extracted, weighing only forty-seven grains. 
The urine resumed its natural course on the eleventh day after the operation, 
and the patient soon fully recovered. He is now a worthy member of the 
profession. 

Besides operating in this case against the will of the patient, there was 
another peculiarity. Sounding just preceding its performance by several pre- 
sent, did not reveal the presence of the stone. Having gone the distance of 
about a hundred and fifty miles, and being confident I had recognized its 
presence in the bladder a week before, I ventured under the circumstances to 
attempt its removal, and fortunately succeeded, notwithstanding its very 
diminutive size. 

Case VIII. — This, too, was a patient twenty years old, having had symp- 
toms of stone from his early youth. Mr. C lived in De Kalb County, 

Greorgia, and was cut with the double lithotome in October, 1847. A large 
mulberry calculus, weighing over an ounce, was broken into two pieces in its 
extraction. Its outer layer is phosphate of lime. The patient had a speedy 
recovery. 

I have performed lithotomy seventeen times within the past four years 
upon patients under the influence of chloroform ; in none did it exercise other 
than good effects. I may have been the first to operate for stone in the 
United States upon a patient under this anaesthetic agent. In all the follow- 
ing cases, chloroform was alone used, and this hi-lateral operation performed. 

Case IX. — Master G- , five years old, has suffered symptoms of calculus 

for the past four years. He resides in Edgefield District, South Carolina, and 
was operated upon in March, 1848. The urine commenced to flow naturally 
on the second day after the operation, the wound healed rapidly, and the boy 
was well in a few days. The size of the stone accurately measured is one and 
a quarter inches and fifteen-sixteenths of an inch in its diameters, but it is 
light, weighing only three drachms. It is the ammoniaco-magnesian phos- 
phate. 

Case X. — Master P , a boy five and a half years old, came from the 

same neighbourhood of the one above, and was cut in May, 1848. He was a 
seven months' child; his mother during gestation had been ill with fever; he was 
altogether quite puny for his age. Difficult urination occurred from infancy. 
A calculus, composed as the one above, in weight two drachms and four 
grains, was removed. On the ninth day the urine resumed altogether its 
natural channel, and the patient was out in the streets in less than two 
weeks. 

Case XI. — This is the most interesting and satisfactory of all my cases. 
One hundred and seventeen calculi were taken from this patient. Mr. 
O'Bannon, then about fifty years old, lived in South Carolina; had been 
injured twenty-four years and four months before being operated upon, 
by a piece of timber striking his spine; soon after this, he experienced 



1852.] 



Eve, Cases of Urinary Calculus. 



45 



difficulty in urinating, which continued until relieved in January, 1849. Pre- 
senting a crepitating tumour in the perineum, which projected more to the 
right side than the left, and detecting by the sound, stone in the bladder, this 
case was operated upon before the class of the Medical College of Georgia, at 
the date just mentioned. An incision was made as in performing the lateral 
operation for lithotomy, except that it was made to the right, and not to the left 
of the raphe of the perineum, and fifty-six small calculi extracted through this 
opening. The grooved staff now introduced into the bladder coming in con- 
tact with other foreign bodies in this cavity, the double lithotome for the bi- 
lateral section was used, and then sixty-one more stones removed from it with 
the forceps; making the whole number one hundred and seventeen. The 
largest of these weighed two drachms thirty-eight grains ; the two next in size, 
seventy-eight grains each; and the smallest, one grain ; aggregate weight four 
and a half ounces. They are of a tetrahedral shape, have polished surfaces, 
are easily fractured, are of a grayish-white colour, and composed of phosphate 
of lime. 

Notwithstanding this patient was reduced almost to skin and bones by his 
long suffering, he yet had an excellent recovery. He sat up a little by the 
fire on the second day after the operation, changed his room on the fourth 
day, on the eleventh was out in the yard of the hospital, and by gentle pres- 
sure upon the wound passed all his urine through the urethra. On the 
eighteenth day from the operation he returned home, a distance of twenty-two 
miles. Upon inquiry, I am happy to learn he still continues well. 

Remarks. — It will be recollected that the largest urinary calculus in the 
British collection was taken, after death (the operation attempted by Cline 
proving. fatal), from Admiral Sir "Walter Ogilvie, who was struck in his back 
by the boom of a vessel when he was twenty-three years old. An injury to 
the spine, like in my case, seems to have been the cause of its production. 
This stone weighed forty-four ounces, and measured sixteen and fourteen 
inches around its axis. 

Case XII. — This was a negro boy coming also from South Carolina, aged 
six years. Lithotomy was performed upon him before the class of the Medi- 
cal College of G-eorgia in February, 1849. The calculus was broken in the 
effort at extraction. It weighed about two drachms. Its composition is uric 
acid. This patient returned home within two weeks. 

Case XIII. — In May, 1849, I cut twice for stone. The first case was in 

Twiggs County, Georgia, and was upon the son of General T , aged four 

years. A calculus, weighing about a drachm, of the mulberry variety, was 
removed from his bladder. During the operation in this case, the rectum was 
punctured, so that gaseous and fluid contents passed through the section made 
in the perineum, but none of the solid feces. As chloroform does not prevent 
the protrusion of this organ while performing lithotomy, I have made a modifi- 
cation in the division of the soft parts by the knife to obviate this accident. 
This will be described at the close of this article. The puncture of the rec- 
tum in this instance was, however, so slight, that the patient was dismissed 
well on the eleventh day after the operation. 

Case XIV. — The other case operated upon, during this month and year, 
was in Coweta County, Georgia, and the patient a lad aged ten years. Master 
B was from infancy a sufferer with symptoms of stone. The calculus re- 
No. XLYII. — July, 1852. 4 



46 



Eve, Cases of Urinary Calculus. 



[July, 



moved is the largest in my collection. It weighed three ounces and one drachm, 
measuring six inches in one and seven and three-quarters in its longest cir- 
cumference. It may be the largest ever removed at so early an age. Its com- 
position is ammoniaco-magnesian phosphate; but the centre of it was not 
examined. 

The wound in this instance had nearly healed, the patient had suffered 
nothing special in the region of the bladder, when unfortunately an attack of 
dysentery, then becoming prevalent in his neighbourhood, destroyed his life. 
His attending physician wrote me that his death was not attributed to the 
operation; and again he writes, March 30, 1852: "I made no post-mortem 

examination of young B ; I have no doubt, however, that his death was 

produced by the affection of his bowels." 

Case XV. — In this case lithotomy was performed, but no stone removed. 

The patient was twelve years old, son of Mr. Z , of Morgan county, 

Georgia, and in addition to symptoms of calculus laboured under congenital 
contraction of the orifice of the urethra. This opening was so small that he 
had frequent retentions of urine. In June, 1850, in the presence of several 
professional friends, the orifice of the urethra was enlarged ; the sound then 
introduced into the bladder coming in contact with a foreign body, the bilate- 
ral section was made. Owing, I presume, to continued distension having dilated 
this organ, it could not be explored with the finger ; still, a calculus could be 
reached, but not seized with instruments. I believe others present were as 
fully satisfied of this as myself, and suspecting the stone to be encysted, the 
case was at this stage of the operation abandoned to nature. 

The wound healed kindly, and in a few days the patient returned home. 
I have several times since, and again more recently endeavoured to obtain the 
subsequent history of this case. On March 29th of this year, I learned from a 

physician related to the family of Mr. Z , "that the operation was of some 

temporary benefit. The improvement, however, continued only a few weeks, 
and the lad is now precisely in the same condition as before it was per- 
formed" — that is, he has symptoms of stone. 

Remarks. — A good deal has been said and some little written in reference 
to the fact of cutting into the bladder when no stone existed in the case, or 
could not then be found. The possibility of this occurring, and without cen- 
sure to the surgeon, must be admitted, however unpleasant the circumstance 
would be to any one. Within the past six months, in a case of retention of 
urine, I was fully confident that the catheter revealed a foreign body in the 
bladder, but which had not been suspected by three other professional gentle- 
men. In a few days, this patient passed the large gravel now in my possession. 
Agreeable to the principles of surgery, lithotomy might have been a justifi- 
able operation at the time I was called into this case ; but there is little doubt 
this small calculous body would have escaped detection by the finger or for- 
ceps introduced into the bladder through a section made intu it. 

Who, need we ask, has not failed to detect stone in the bladder when one 
existed at the very time of the examination ; or who has not been deceived in 
the sensation imparted by the sound? Even with the free, full, and unbiased 
exercise of all the senses, how fearful are we of committing errors in diagnosis 
In reference to affections less obscure than those of the bladder? In detect- 



1852.] 



Eve, Cases of Urinary Calculus. 



47 



ing urinary calculi, we are unfortunately limited to two of the perceptive facul- 
ties ; hence the great liability to mistakes. The distinguished Samuel Cooper, 
long at the head of surgical literature in Great Britain, declares he knew of at 
least seven cases, at two of which he was present, where the patients were 
subjected to lithotomy, and no calculi found in their bladders. 

The greater Cooper, Sir Astley, says he has failed to detect anything when 
others have discovered a calculus. He cut one patient and extracted thirty- 
seven stones from his bladder, though he had been sounded and declared not to 
have one. In a case in which the urine had been repeatedly drawn off, and 
no stone could be felt after the patient's death, fifty-six, he states, were found 
in the bladder. 

But still more to the point resembling my own case. This celebrated sur- 
geon cut a boy in G-uy's Hospital, wherein he supposed the sac of the encysted 
stone was alone opened, situated as it was between the bladder and rectum, 
and without wounding either of these organs. This patient recovered. In 
another case, he found by inspection after death two calculi having large ex- 
tremities connected by a narrow stem; one extremity of each was situated in a 
sac, and the other extremity in the cavity of the bladder. 

Sir Benjamin Brodie relates a case in which the patient only occasionally 
suffered symptoms of stone. Dying of pleurisy, a perfectly formed cyst was 
found embracing the calculus ; but in such a manner that he suspected this 
foreign body to have escaped into the general cavity of the bladder only at 
the periods when he actually experienced the symptoms of cystic irritation. 

A curious case is mentioned in a recent journal, in which, at a consultation, 
I think, of about fifteen surgeons, the question of the presence of stone in 
the bladder was decided in the affirmative by one vote, and the operation of 
lithotomy performed. No calculus was found; the patient, an adult, was 
cured, nevertheless, of all his symptoms, but never once asked to see the 
foreign body supposed to have been extracted. 

Cheselden cut thrice, and found no stone. Roux, the present veteran sur- 
geon of the Hotel Dieu, has performed lithotomy four times without finding a 
calculus. Dupuytren acknowledged having done this once; and Dr. Physick 
was very near doing the same thing. He had no doubt the stone existed, but 
would not operate because the health of the patient was bad. He died before 
the preparation for it was completed, and on examination nothing foreign was 
found in his bladder. Crosse, the celebrated lithotomist of Norwich, England, 
admits he cut in one instance a child affected with polypus, and not stone of 
the bladder; and says, he has notes of not less than eight cases in which sur- 
geons expected to find calculi without doing so. Desault has also committed 
this error. 

Professor Ford of this city sent a case to me, in 1849, which was quite simi- 
lar to the one which has drawn forth these remarks. It was a boy about 
eighteen months old, whose almost closed orifice of the urethra I enlarged, 
when a copious gush of urine relieved the distended bladder. Not suspecting 



48 



Eve, Cases of Urinary Calculus. 



he had symptoms of urinary calculus, he was not sounded. A short time 
afterwards, he was killed by the shaft of a dray falling upon his head, when 
all that his parents would permit Dr. F. to do was to feel the stone by the 
catheter, which, he says, was unequivocal. 

A case of sacculated or encysted calculus is published in the Monthly Jour- 
nal of Great Britain for February, 1848, by Prof. James Miller, of Edin- 
burgh. He says : " Again using the forceps, sometimes as a sound and some- 
times as forceps, I could make no seizure; often coming in contact with the 
stone, but never being able to include it in my grasp. I changed the forceps 
once and again, using different sizes and forms ; but with a like want of suc- 
cess." He then requested his friend and colleague, Dr. Duncan, to take his 
place; but he likewise failed to remove the calculus. This they could feel 
but not seize, and became satisfied it was firmly grasped and protected by the 
bladder; either sacculated or encysted, they could not tell which; for it was 
far from the point of the finger, and could be reached only by the instruments 
introduced. By repeated efforts, the stone was extracted, but the patient 
died. 

I agree with M. Civiale that an examination with lithotrity instruments 
tends greatly to correct the diagnosis of ordinary sounding the bladder and 
the exploration by the finger in the rectum. 

Case XVI. — -In October, 1850, just before leaving for Louisville, Ken- 
tucky, I operated for stone at Midway, near Milledgeville, Georgia, on the 
son of Mrs. H., aged seven, who had presented evidences of urinary calculus 
from early childhood. A very rough fusible calculus, the triple phosphate of 
ammonia, magnesia, and lime, was removed, in weight about half an ounce. 
In ten days after this, the patient was well. 

Case XVII. — Master S., the son of German parents, who settled first in 
Charleston, South Carolina, where he was born and resided until a year ago. 
He was sounded in that city, but nothing special elicited. Having returned 
early in February, 1851, from the West, lithotomy was performed on this 
patient before several members of the class then in attendance at the Medical 
College of Georgia. A mulberry calculus weighing about half a drachm was 
extracted, and the boy returned home to Graniteville, in his State, in a week. 

Case XVIII. — In March, 1851, I operated upon Master J., seven years 
old, coming from Elbert County, Georgia. His mother states explicitly that, 
when only four days old, she noticed he suffered during micturition. A cal- 
culus of uric acid, three drachms in weight, was taken from this patient. 
Hemorrhage occurred during the night after the operation, but was arrested 
by a female catheter having a linen pocket attached to it, and stuffed with 
cotton after its introduction through the wound into the bladder. The patient 
left for home within two weeks. 

Remarks. — The calculus in this case was in all probability congenital. 
The earliest period of life at which we find lithotomy was required is men- 
tioned by Civiale as occurring at ten weeks old. The result of the operation 
is not given. 



1852.] 



Eve, Cases of Urinary Calculus. 



49 



Case XIX. — The son of a professional brother, Dr. S., in Coweta County, 
Georgia, was cut in June, 1851. He was seven years old, had two friable 
calculi, one of which was removed nearly whole, the other after it was broken 
up. They would weigh about three drachms, and are composed of oxalate of 
lime nuclei covered with about one-eighth of an inch of phosphate of lime. I 
have just received a letter in which occurs the sentence : " The condition of 
Dr. S.'s son is such as you would desire it to be, a perfect cure." 

Case XX. — Up to this number, but one of my patients had died after 
beirig operated upon; all had fully recovered with a single exception, and 
death in that instance was not attributed to lithotomy. But of my remaining 
cases, that is, of the last six operations, no less than three had a fatal termi- 
nation. 

The first of these was in the person of Mr. T., of De Kalb County, Georgia, 
aged seventy-seven. He had been afflicted for years with calculous symptoms; 
for the last ten had daily used a catheter; knew he had a stone in the blad- 
der, for, besides feeling it with his silver catheter, its eyes or openings near 
the beak would occasionally be plugged with fragments of a urinary concre- 
tion; and, having endured the extreme of human suffering, now demanded, at 
all hazards, an operation. The usual bilateral section was made, but, owing to 
the size of the prostate gland, the bladder could not be explored with the 
finger. As in Case XV., a foreign body could only be felt, but not seized 
with instruments. After repeated efforts, the fragment of a calculus, size of 
a rifle-ball, was detached by the scoop ; the operation was now discontinued, 
and the old gentleman died at the end of sixty hours, of course from the 
direct effects of it. 

His family physician, Dr. E. N. Calhoun, fortunately made a post-mortem 
examination, and thus describes the condition of the organ opened in the ope- 
ration : " After cutting into it (as in the high method for stone), I found the 
walls of the bladder thickened to the extent of from one-fourth to three- 
eighths of an inch, and perfectly infiltrated with blood. It contained a large 
quantity of bloody water, of course very offensive, and there were three dis- 
tinct cysts, each containing quite a number of small calculi. The one sent" 
(about the size of a partridge's egg) " I took from the sac nearest the fundus." 

Case XXI. — This was my first in Tennessee, and was operated upon in 
November, 1851. 3Ir. T., aged twenty-four, had suffered calculous symp- 
toms for years, and had recently returned from a visit to California by the 
Isthmus. He was cut in the presence of several members of the medical 
class of the Nashville University, and a very rough mulberry calculus, weigh- 
ing about half an ounce, removed. In physical appearance, it resembles very 
much the one removed thirteen months before, near Milledgeville in this 
State, but differing widely from it in composition. 

The bleeding was rather free after the operation ; but a careful examination 
did not expose any particular vessel from which it proceeded; the blood 
seemed to be derived from the plexus about the neck of the bladder. It soon 
ceased to return during the night after the expulsion of a coagulum, when it 
was permanently arrested, as in Case XVIII., by a female catheter, armed 
with a linen pocket and stuffed with lint. 

This patient was ready for home in less than two weeks. 

Case XXII. — On the 10th of December, 1851, I removed, in Nashville, 
a calculus from the daughter of Dr. D., of Tennessee, on her fifth birthday. 
The double lithotome introduced into the bladder touched the foreign body; 



50 



Eve, Cases of Urinary Calculus. 



it was turned half round, as in operating upon the male ; the blades expanded, 
and in withdrawing the instrument as soon as the cutting edges appeared at 
the mouth of the urethra, these were closed. The object of this peculiar 
method was to divide the orifice of the urethra to as limited an extent as was 
possible for the extraction of the stone. Dilatation was now effected, and a 
calculus measuring nearly three inches in its greatest circumference was re- 
moved. Its composition is oxalate of lime. 

In thirty-six hours after the operation, the patient was apparently well; 
the second night, she retained her urine, rising twice to evacuate it; and, on 
the fifth day, she left the city for home in an open buggy, with the tempera- 
ture below the freezing point. I learn, subsequently to this, her perfect 
recovery. 

Remarks. — This little girl lived for three years in a calcareous region, 
where the ordinary drink was strongly impregnated with lime; after this, she 
used free-stone water, but had an attack of genuine variola, and, during con- 
valescence from it, experienced an inordinate thirst for acids, which was freely 
indulged by allowing her pickles, crab apple cider, &c. She now presented, 
for the first time, symptoms of urinary calculus. It may be that the alkali 
and acid, thus introduced into the system, stand in the relation of cause and 
effect as regards the production of stone in this instance. 

Case XXIII. — A boy, seven years old, son of Mr. G-., was brought before 
the class of the Nashville University, through the kindness of a professional 
brother, for diagnosis in regard to a vesical affection. He had been sounded 
without detecting stone; now, one was recognized. He was cut on the 5th 
of February, 1852, and an oblong calculus, weighing about a drachm and 
a-half, removed. It is of a dirty-yellowish colour, and oxalate of lime com- 
position. 

The wound healed by the first intention. The attending family physician 
and myself made daily examinations of it, and to our repeated inquiry of the 
mother who nursed the patient, she gave the invariable answer, there has 
been no discharge from the cut in the perineum. The boy sat up in three 
days after the operation; took one dose of opening medicine, in a week was 
running about, and presented again to the class sound and well. 

Case XXIV. — During the same month (February), lithotomy was again 
performed before the class of the University. This patient was aged twenty- 
four, and was apparently suffering the extreme of human endurance with 
stone in the bladder. He decided for an operation because a neighbour 
labouring under the same affection had just died, and from whose bladder, 
after death, a large calculus was taken. So urgent were the symptoms in the 
present case that every preparation was hastened for relief. The warm bath, 
demulcent drinks, opiates, &c, were prescribed with little avail, for, on the 
night previous to the operation, he soiled the floor of his chamber with some 
six or eight small puddles of urine which he had spasmodically passed lying 
upon his abdomen. 

When brought before the students on the morning of the 16th, they were 
told how unfavourable was the case for operating, yet how urgent the demand 
for it. W aiving every other consideration but the relief of the patient, the 
bilateral section was made into the bladder, but, owing to three circumstances, 
the operation was protracted for nearly an hour. We have the candour to 



1852.] 



Eve, Cases of Urinary Calculus. 



51 



admit, it was badly performed. Chloroform did not act favourably ; the open- 
ing in the prostate was not large enough for so voluminous a calculus ; and 
having had my own forceps misplaced, and using too small a pair, the stone 
was crushed by the efforts at extraction. It is composed of phosphate of 
lime. 

The patient gave hopes of doing well up to the third day, when, unfor- 
tunately, erysipelas invaded the whole scrotum, terminating in mortification, 
and his death on the sixth day after the operation. I was in the country, 
engaged with another case of lithotomy, when he died, and no post-mortem 
was made of the body. 

Case 3£XV. — During my winter sojourn at Nashville, I had several times 
been consulted by the friends of Colonel K., who was quite a sufferer from 
urinary calculus. He was a large, fleshy man, weighing over two hundred 
pounds; of excellent constitution; good health, previous to the present affec- 
tion; of most exemplary habits; and I found him, the last of February (this 
year), urgent for an operation, to which he had been brought, as the last re- 
source, for relief. The past summer, this patient thought he was deriving 
benefit from a newly-discovered spring in Tennessee, and was induced to be- 
lieve the water was even dissolving the stone, as he passed several considera- 
ble fragments, seemingly the layers or concentric laminae of a larger mass. 
At the time of the operation, he had been confined not only to his room, but 
even to his bed, for several months. He had been out but once since Octo- 
ber, and then only on account of an alarm that his house was on fire. 

Colonel K. was now sixty-five years old ; had experienced his present symp- 
toms four or five years; been passing fragments of a urinary concretion for 
eight or nine months; and resorted constantly to the catheter to relieve reten- 
tion. Notwithstanding his emaciation from intense suffering, he still pre- 
sented a stout frame in a good constitution, and enjoyed a firm reliance in 
the Christian's hope. With the full understanding, on his part, that his case 
was an unfavourable one for operating; that we knew the stone was already 
broken up; that he was greatly reduced in strength and body, and yet was 
quite fat; that the season of the year was unpropitious; and that, in the con- 
sultation of his five physicians, it was decided the prospects for life and death 
were equally balanced, lithotomy was performed. Such a prostate gland I 
hope never again to encounter. The bilateral section was, however, fairly 
made, but, from the size of this body, it was impossible to pass the finger be- 
yond it, much less explore the bladder. With the scoop and forceps, several 
pieces, one much larger than the others, apparently the nucleus, of a con- 
siderable mass, were extracted. It is the triple phosphate. 

The following extract from a letter of the patient's family physician gives 
the subsequent history of this case : — 

" Lebanon, Tennessee, April 1, 1852. 
"I remained with Colonel K. twenty-four hours after the operation, and 
everything seemed to promise well. He slept well, and passed his urine both 
through the wound and urethra. I left him full of hope that my much valued 
friend would recover and enjoy many years of health. I did not return to 
see him until the ninth day after the operation ; but how changed his condi- 
tion ! * * * The wound was gangrenous; there was also a slough as large 
as a dollar on one of his nates, and another at the verge of the anus. He 
lingered till Tuesday morning." 

Remarks. — This patient, too, in all probability fell a victim to erysipelas ; 



52 



Eve ; Cases of Urinary Calculus. 



[July, 



at least we are left to infer as much. I believe, under the circumstances, I 
did my duty in operating in this case. He could not well have been brought 
to Nashville. Were it not for the immense size of the prostate gland, judged 
to be two and a-half inches in length by an inch thick, and his distance from 
the conveniences of a city, possibly lithotrity might have relieved him. 

In reference to the cause of breaking the stone while in the bladder, we 
know of no better explanation than that offered in the following quotation 
from Mr. South. He says, Sir Benjamin Brodie gives the history of a case, 
in which the patient, " having, for a considerable time, laboured under the 
symptoms of stone in the bladder, began to void by the urethra what had all 
the appearance of portions of a large calculus, broken down into fragments 
of various shapes and sizes. The number of these fragments at last amounted 
to more than two hundred, and now the discharge ceased, the symptoms at 
the same time subsided, and the patient being restored to perfect health. In 
this instance, the discharge of the fragments of the calculus was attributed 
to the use of certain mineral waters." Prout mentions a case, in which, 
however, the same happened without the patient using mineral waters or any 
kind of medicine j and Crosse speaks of numerous fragments which he obtained 
from a gentleman after a ride on horseback; as well as of twenty-two cal- 
culi removed after death, from a patient seventy years of age, which are of a 
very irregular shape, but admit of being so arranged as to form four regular 
and well-shaped calculi, each of the size of a pigeon's egg, which, with the 
appearances of the different surfaces, proves that the calculi had been broken 
in the bladder by knocking against each other under certain movements of the 
body. Other cases are also alluded to. and in the Museum of the Koyal 
College of Surgeons there are several similar broken stones. 

In my case it is more probable that the rough ride to the spring had more 
to do in breaking up the stone than drinking its waters had in its dissolu- 
tion. 

Recapitulation of the twenty-five Cases. 

Sex. — 23 were males, and 2 females. 

Race. — 2 were black, 2 mulattoes, and 21 white. 

Age. — 16 were under thirteen years, 7 between twenty and thirty-five, 1 
at sixty-five, and 1 at seventy-seven. 

Operation. — 24 were cut, 23 of which by the double lithotome. 

Result. — 4 died after being operated upon, 3 of which from the operation, 
2 indirectly (supervention of erysipelas), and only 1 directly from it. The 
remaining 21 fully recovered. Of the 19 first operated upon, but 1 died ; and 
in that instance, death was not owing to lithotomy. 17 were well in two 
weeks after the bilateral operation. In no case have I heard of the reproduc- 
tion of stone, nor has a fistula occurred in one. 

Number of Calculi and their Chemical Constituents. — Single in twenty-two 
cases, 2 in one case, 3 in another, and 117 in another; total, 144 stones in 



1852.] 



Blake, Climate and Diseases of California. 



53 



the twenty-five cases. Composition, chiefly some preparation of lime. There 
is not the usual proportion of the uric acid formation. Of the five specimens 
obtained in Tennessee, each contained lime ; thus confirming Prof. Peters' 
analysis of the Dudlean collection of calculus at Lexington, Kentucky. It 
would seem from this collection that phosphate of lime is not so rare a com- 
position of urinary concretions as is generally supposed. 

My method of performing lithotomy is now submitted, but claiming for it 
nothing original. 

It will be seen that decided preference is given to the bilateral operation of 
the late distinguished French surgeon, Dupuytren. I have found that, owing 
to the irregularity of the external surface operated upon, it was difficult to 
make the crescent-like shape or the semicircular incision through the skin 
and soft parts. I now make the cut like a J^, with a short tail. The grooved 
staff previously introduced into the bladder, and the scrotum elevated by an 
assistant, a short incision is made directly upon the raphe of the perineum at 
the bulb of the urethra, and the direction changed at a very oblique angle at 
the end of about three-quarters of an inch, to terminate at a point midway 
between the anus and left tuberosity of the ischium. With the edge of the 
knife now turned upwards, it is made to penetrate and commence the other 
leg of the at the point of the right side corresponding to the one just ter- 
minated upon the left. This incision is deepened as the instrument ascends, 
and, arriving at the middle of the perineum with the edge turned directly up- 
wards, the urethra is opened, and the groove of the staff exposed. This not 
only simplifies the external incision of lithotomy, but effectually guards against 
the liability to wound the rectum. The operation is then completed in the 
usual way. 

The suggestions made in the Southern Medical and Surgical Journal, in 
1849, in regard to the instruments, I expect to have carried out this summer 
while in Paris; and they may hereafter be presented to the profession. 

Augusta, Ga., April, 1852. 



Art. IV. — On the Climate and Diseases of California. — By James 
Blake, M. R, F. R. S. 

The investigation of the modifications produced on diseased action by 
the influence of external circumstances opens an interesting field to the 
researches of the medical philosopher; for it presents an example of an 
experiment made by nature on a vast scale, in which some of the most 
important elements modifying disease are so completely changed, that we have 
an opportunity of observing the phenomena they present, under circumstances 



54 



Blake, Climate and Diseases of California. 



which would never have been produced by artificial means. This consideration 
invests the subject of the investigation of disease in this country with a 
degree of interest which renders it worthy the attention of those who take a 
pleasure in elucidating its complicated phenomena ; and whilst fully realizing 
the importance of such an investigation, I have to regret that the data which 
a limited practice has enabled me to collect can throw but little light on the 
subject. The facts, however, that have been observed, in relation to the 
climate of our winter months, will probably be interesting to many of your 
readers. The data recorded have been only those which are likely to in- 
fluence the progress and character of disease, and, as it will save space, I will 
present them in a tabular form. 





Nov. 


Dec. 


Jan. 


Feb. 


March 


April 










1 to 16. 


8 to 3L. 


Mean temperature 


51° 


44.6° 


47.7° 


49.2° 


52.2° 


60.7° 


Highest temperature 


73 


68 


70 


71 


79 


93 


Lowest temperature 


31 


26 


31 


28 


32 


39 


Mean of maxima .... 


66.2 


57 


60 


64.4 


66.6 


77.5 


Mean of minima .... 


4^2.6 


36 


37.2 


37.8 


44 


49.3 


Mean temperature of north winds 


48 


41 


46 


51 


51 


63 


Mean temperature of south winds 


55 


50 


50 


49.5 


50.7 


58 


Mean minima of north winds 


34 


32 


38 


39.5 


37 


49.2 


Mean minima of south winds 


48 


43 


39 


38.5 


42 


48.5 


Number of days of north wind 


15 


7 


10 


6 




y A ■>> 


Number of days of south wind 


12 


S 


4 


4 


12 


12 


Number of calm days . 


13 


16 


17 


6 




14 


Number of clear days . 


16 


20 


19 


13 


9 


13 


Number of cloudy days 


7 


6 


6 


..3 d 


8 


12 


Number of rainy days . 


7 


5 


3 




7 


4 


inches. 


inches. 


inches. 




inches. 


inches. 


Amount of rain 


2.7 


2.5 


0.7 




2.5 


1.8 



From the above table it will appear that the most important feature in the 
climate of this country, during the winter months, is its equability. In no 
instance has the thermometer fallen more than 21° below the mean tempera- 
ture in any one month, and the difference between the mean temperature, 
taken at the coldest part of the day, and the lowest temperature observed 
during any month, does not exceed 11°. This fact presents a striking con- 
trast with the variations of temperature observed in the Atlantic States, where 
it is not at all uncommon to find the thermometer descending thirty or forty 
degrees below the mean temperature, even of the minima. In Rome, where 
the average temperature of the winter months is about the same as here, the 
thermometer sometimes descends as low as 23°, whilst here it has not 
been noted below 26°; and there can be no doubt that the winter of 
1850-51 was a cold one, on account of the absence of strong southerly winds 
and rain, which are always accompanied, during the winter months, by a higher 
temperature. From ail I could learn from those who had been in the country 
for many years, the temperature of 26° was a cold they had never before 
experienced. This season, 30° is the lowest point that has been reached; in 



1852.] 



Blake, Climate and Diseases of California. 



55 



fact, the temperature of the winter months is most congenial, being generally 
about 36° at sunrise, rising to about 60° during the day, and again falling 
towards evening. 

The direction of winds in this part of the valley is, as a general rule, 
N. and S., or varying but very slightly from these points. I have never 
observed an easterly wind,' and this absence of easterly winds is a fortunate 
circumstance as regards the climate of the valley, as a strong wind from that 
direction, blowing across the snowy peaks of the Sierra, could not fail to 
bring with it unpleasant indications of the country it had travelled over. 
The influence of the winds on the temperature varies according to the season 
of the year. In the winter months, the north winds are the colder, and 
the south winds, which, when strong, are always accompanied by rain, are 
warm. Towards the spring, the north winds become warmer, on account of 
the sky being generally clear when these winds are blowing, and the sun 
having more power raises the temperature. It will be seen, however, that the 
mean minima of the north winds, or the lowest temperature observed on those 
days on which the wind is from the north, is still below the minima of south 
winds until the month of April, when the summer climate decidedly shows 
itself, in which the north winds are always the minima. As regards the force 
of the winds, it is generally but slight; it only blew hard from the south twice 
during the whole of last winter, and the north winds are generally very light. 
The atmosphere is usually calm, or only agitated by slight local currents. 

It will be seen, also, by the tables, that the sky is, as a general thing, 
clear, and this is so during the only season of the year in which a cloud is ever 
to be seen in the heavens. The quantity of rain that fell during the winter 
of 1850-51 was about eleven inches: there can be no doubt but this was 
much below the average, and probably not more than a fifth of what fell in 
1849-50. During the whole of the winter months, the air is decidedly moist, 
the dews are extremely heavy at night, the air is frequently loaded with fogs in 
the morning, and it is rare to see a difference of more than six or eight 
degrees between the wet and dry bulb thermometers. 

On account of being engaged in geologizing in the mountains during the 
summer, I have not any extensive series of observations showing the nature of 
the climate during this season. The principal characteristics of our summer 
climate are, a high temperature during the day, cool nights, and a dry state of 
the atmosphere. From some few observations made at Sacramento, during the 
months of July and August, the average temperature at sunrise was 63°, at,3 
P. M. 94°. The highest temperature noted was 98°, although I was not in the 
valley during the hottest days. On one occasion, last summer, the thermometer 
rose to 106 in the shade; this was in the mountains, and it is probable that the 
thermometer was almost as high in the valley. During the summer months, 
a southerly wind generally prevails, rising about eight or nine o'clock in the 
morning, and continuing until sunset, or even during the whole of the twenty- 
four hours. This tends to moderate the temperature, tempered, as it im- 



56 Nivison, Opium and Sulphate of Quinia. [July 

far reduce the biliary and renal secretion as to incur the risk of fatal tox- 
aemia. Combined with quinia this tendency is to a great extent counter- 
acted. 

3d. Opium frequently reduces the respiratory action to such an extent 
that we are liable to have all the evils incident to imperfectly aerated 
blood. If, under these circumstances, we invoke the " antagonistic" effects 
of quinia, these unpleasant consequences are usually averted, while all the 
desirable effects of the opiate are retained. 

4th. The after effects of opium are frequently so unpleasant as to neu- 
tralize or perhaps overbalance all the good that would otherwise result. 
These usually do not appear when the remedy is administered in combination 
with quinia. 

5th. In many cases of extreme exhaustion, such as follows protracted 
hemorrhages and other like debilitating causes, we can temporarily arouse 
the energies of the system by the free use of opium ; it is in fact the sheet- 
anchor; often the only hope. When the sensibilities of the system are 
thus reduced, the toleration of this drug is often truly astonishing. Under 
these circumstances, however, it not unfrequently happens that the quantity 
which is barely sufficient to produce the reaction is yet sufficient when it 
does occur to produce unpleasant narcotism. If in these cases we give 
quinia with the opium, we not only secure the desired action with a less 
amount of opium, but the more protracted operation of the quinia will 
enable us to maintain the reaction for any desired length of time without 
those frequent repetitions of the opium that would otherwise be necessary. 

We may mention in this connection that persons who from accident or 
design have taken overdoses of opium and are found in a state of narcotism, 
are often promptly aroused by the administration of a full dose of quinia, 
This is especially the case in young children, who usually tolerate opiates 
very badly. 

6th. Many patients from idiosyncrasy cannot take opium. When given 
in combination with quinia a large proportion of these persons take it 
without inconvenience. 

We might multiply these examples were it necessary; but if we are thus 
far correct, quinia is a valuable adjuvant and often corrects the unpleasant 
effects of opium. 

It may perhaps serve to illustrate the foregoing propositions to state 
that other agents than quinia, as the peculiar mental condition of lunacy, 
the continued effect of cold, &c, will sometimes neutralize the bad effects 
of opium without impairing the good ones. Mr. Skey being obliged to 
ride all night in December when he had forgotten his overcoat, says : "After 
riding ten miles I took twenty-five drops of laudanum, and rode the remain- 
der of the night without inconvenience." He says, it may be asked "What 
was the effect on the following day?" and replies, "None whatever. The 
cold and the opium mutually balanced each other; there could be no reac- 
tion, for the duration of the cold exceeded that of the opium." 



1861.] 



Nivison, Opium and Sulphate of Quinia. 



51 



I am inclined to think the action of the quinia in this regard analogous 
to that of the cold. The duration of its action generally exceeds that of 
the opium, thus supporting the system till the effects of the opium shall 
have passed away. 

On the other hand, certain well-known effects of quinia are often de- 
sirable where, from peculiarity of circumstances, we either cannot obtain 
them, or, doing so, we bring with them such an undesirable train of con- 
comitants that we are forced to dispense with the article altogether. We 
will notice a few of these peculiarities very briefly. 

1st. The prominent feature of many diseases is dangerous congestion of 
some internal organ or organs. Here the well known action of quinia in 
giving contractility to the capillaries of congested parts is exceedingly 
desirable; but where, on trial of the remedy, we find we have imparted only 
a peculiar excited action to the general circulation, under the influence of 
which the congestion is aggravated rather than relieved. The addition of 
a sufficient amount of opium to control this excitement will not only insure 
the legitimate operation of the quinia on the capillaries, but by diverting 
the general circulation to the surface, aids still further in overcoming the 
congestion. In this class of cases either opium or quinia acting alone 
would almost certainly add to the existing congestion ; in combination the 
bad effects are neutralized, and the two remedies co-operate in producing 
the desired relief. 

2d. There are many forms of inflammation to which, mutatis mutandis, 
the above remarks will apply with equal force. Judicious combinations of 
the remedies in question will often give us the most perfect control of the 
vital forces, and enable us to fulfil the various indications in the most satis- 
factory manner. There are many points of interest involved in this branch 
of our subject, in the discussion of which the limits of our article forbid us 
to enter. (For much that is valuable on the points here involved we refer 
to the Dublin Hospital Gazette for July, 1856, and the Dublin Quarterly 
for August of the same year.) 

3d. There is another great class of diseases in the treatment of which 
quinia is almost indispensable. I allude to the idiopathic fevers. Here 
also we are liable to have various disturbing symptoms demanding the use 
of opiates. Experience has demonstrated that they may be combined with 
quinia with the most beneficial results. 

4th. There are various affections usually denominated neuralgic, which 
are palliated by opiates and sometimes cured with quinia. These cases 
will often yield more speedily to the combined influence of opium and 
quinia than to any other known remedies. 

5th. There are numerous morbid conditions belonging to the neuroses, 
often associated with anemic states of the system where the true etiology of 
the disease can doubtless be traced to defective nerve nutrition. We have 
already had occasion to notice the action of both opium and quinia in 
modifying and improving the function of nutrition. In the present state 



58 Blake, Climate and Diseases of California. [Juty? 

system. On this point I can myself testify ; for, although without any appa- 
rent sickness, yet for the first three weeks after my arrival in the country, 
from crossing the plains, I was so prostrated that I could lie on my bed 
during the whole day, without the slightest energy, either physical or mental, 
and many of my friends were affected in the same way. Disease, I believe, 
is often brought on by men attempting to work while in this state of prostra- 
tion. The diet, also, was a fruitful source of disease, not only as regards its 
quantity, but even its quality. The only fresh meat to be had was beef, and 
this was generally fried, or rather boiled in rancid lard; the flour was to a great 
extent damaged, and the butter and salt meat were all more or less rancid. 
I state these facts to show that, although diarrhoea and dysentery prevailed 
here to so great an extent, and so fatally, during the fall of 1850, the causes 
of its ravages are to be looked for principally in the unfavourable circum- 
stances in which the population was placed, rather than to any malarious in- 
fluence. But not only were these circumstances fruitful sources of disease, but 
they presented an almost insurmountable obstacle to recovery, even when the 
more violent symptoms had been subdued. There was no such thing known here 
as that valuable hygienic remedy called nursing. From the toast water of the 
sick room your patient had to go back to the beef, salmon, and rancid grease 
of the boarding-house. There were none of those light and valuable edibles 
which gradually lead the invalid by a safe path back to his ordinary diet. 
Relapse after relapse occurred, and it wanted but little assistance from the 
diarrhoeic influence which generally precedes the appearance of cholera, to 
produce a state of gastro-enteric disease amongst four-fifths of the newly- 
arrived population. 

In this state of the general health, the cholera made its appearance about 
the beginning of November, and never did it fall on a population so prepared 
to yield to its ravages. Although it is impossible to obtain any accurate data 
as to the number of its victims, yet I am confident that, during the few days 
at which it was at its height, not less than one per cent, of the population was 
daily carried off by it. There was nothing peculiar in the disease as it occurred 
in this country ; its apparent virulence can be accounted for by the previous 
state of those attacked. The tables appended, showing the returns from the 
State hospital in this city, prove that, even during the summer and autumn 
months, there is very little tendency to gastro-enteric disease, at least when 
the exciting causes above alluded to are absent. 

The diseases more particularly characteristic of the winter months are typhus 
fever, rheumatism, erysipelas, and pneumonia. The cases of typhus that 
came under my care were of a mild form, although generally lasting from 
fourteen to twenty-one days. In none of the cases which I treated did any 
unfavourable symptoms present themselves. The treatment was purely ex- 
pectant, with the exception of quinine or bark, and stimulants towards the 
latter period of the disease. In two instances, the rose-coloured spots were 
noticed on the sixth day of the disease. From the returns of the State hos- 



1852.] Blake, Climate and Diseases of California. 59 



pital, it would appear that this disease was prevalent during the autumnal 
months of last year, and the mortality was 39.7 per cent., a decidedly large 
mortality. Only three cases were admitted from the city, the others being 
brought in from the country. 

The cases of pneumonia showed themselves soon after the first rains, and 
could generally be traced to exposure to wet and cold : they were very amena- 
ble to treatment. But three cases came under my care, and in every case the 
patients made a rapid recovery, the time of treatment averaging nine days. 

Rheumatism was one of the most common diseases during the winter 
months of '50 and '51, attacking principally those who had been previously 
affected by diarrhoea and dysentery; and in these it generally presented itself 
with very troublesome, and in fact alarming, symptoms. The disease was 
generally of a low type, and in every case that came under my care was ac- 
companied by inflammation in the muscles, or at least in the aponeuroses ; 
this inflammation was the principal and most distressing symptom. In two 
of these cases, suppuration took place; in one subject, in the calf of the leg, 
under the gluteus maximus and under the trapezius ; and, in the other, in the 
calf of the leg. In three other cases that I treated, these swellings were 
present in the calf of the leg, and although I was led strongly to suspect 
that pus had formed, yet they recovered without any abscess being opened. 
Pericarditis existed in three cases, but, notwithstanding the unfavourable 
character of the general disease, this complication did not present itself in a 
severe form. One of the cases terminated fatally, that in which matter had 
formed so extensively. I believe the case would have been saved had it 
remained under my care; I was, however, superseded by a herb doctor, 
whose first care was to bind up the abscesses as tightly as possible to prevent 
the discharge from weakening the patient. The treatment adopted was 
the administration of colchicum and quinine, and sometimes sulphate of iron ; 
recovery was slow; the average time of treatment being forty-one days. I 
had an opportunity of seeing some other cases in which the same symptoms 
showed themselves. Rheumatic affections are not so common amongst the 
mining population as we might be led to expect from the exposure to which 
they are subject, working, as too many of them do, for hours at a time in the 
water, and also frequently exposed to rain. But very few cases of this dis- 
ease have been admitted into the hospital during the past year, and this is 
probably owing to the absence of diarrhoea and dysentery, which seem to exert 
a peculiar influence in predisposing the system to rheumatism. 

Erysipelas is a disease which has been extremely fatal in the country 
during the last twelve months; but it has existed to a greater extent in the 
mountains than in the valley. During the course of last winter, five cases 
came under my care; in all of these, the head was the only part involved, 
with the exception of one in which the inflammation spread to the shoulder 
and chest ; three of these cases occurred in the same house, and the first case 
that showed itself was in a man who had been living in another house in the 



60 



Blake, Climate and Diseases of California. 



[July, 



country, where there was a case of the disease. The most striking peculiarities 
of these cases were the inflammation of the mucous membranes communicat- 
ing with the natural openings, and the absence of that amount of general and 
cerebral disturbance which so often renders erysipelas of the head a formida- 
ble disease. In every case, the mucous membrane of the mouth and fauces 
was inflamed; in four cases, there were ulceration and discharge of fetid pus 
from the nostrils; in three cases, the palpebral conjunctiva was severely af- 
fected; and, in four of the cases, there was discharge of pus from the ears. 
And yet, notwithstanding these symptoms, the cases in which they presented 
themselves were attended with as little cerebral and general disturbance as 
any I have ever seen, in which the head was involved. The fever never rose 
high, nor was depletion required in any case. A dose of blue pill and castor 
oil, and then quinine, combined with small doses of blue pill and rhubarb, 
was the treatment usually adopted. The only case that terminated fatally 
was a man of intemperate habits, who died from a complication of the disease 
with pneumonia. The average duration of the treatment was nine days. 
This disease is of frequent occurrence in the mountains, and I have seen many 
cases of it during the summer. The localities where it mostly prevails are the 
deep valleys in the mountain districts, which are shut in on all sides by high 
hills, where the extremes of temperature are great, and the air has a tendency 
to become stagnant. In some of these places it has proved extremely fatal, 
the mortality being more than fifty per cent. This large mortality is to be 
accounted for partly by the intemperate habits of many of the subjects at- 
tacked by it, but also in a great measure, I believe, from the too general use 
of calomel, and from not giving quinine and tonics at an early period. In 
two of the cases that came under my care, granular conjunctivitis remained 
as a sequela of the disease, and I have seen some very severe cases of this 
affection that have been produced by it. 

Diseases of the air-passages are extremely rare. A mild form of catarrh 
showed itself apparently in an epidemic in February, 1851, and the same 
affection is occasionally met with during the winter months; but I have not 
yet seen a case of acute bronchitis, and the experience of many of my medi- 
cal friends in the city is to the same effect. This is probably owing to the 
absence of cold dry winds during the winter months. Yery few cases of 
phthisis are met with, considering the circumstances in which so large a por- 
tion of the population is placed, and which in other climates could not fail to 
develop the latent germs of this disease which exist in so many individuals. 
Speaking from my own limited experience, it is more amenable to treatment 
here than in any other country in which I have practised. Two cases of the 
disease in an early stage have come under my care, occurring in individuals 
who had a strong constitutional tendency to it; in each case, haemoptysis to 
some extent had occurred, and that partial solidification of the lung, indicated 
by the prolonged rough expiratory murmur evidently existed. One of these 



1852.] 



Blake, Climate and Diseases of California. 



61 



cases has apparently quite recovered; the individual having enjoyed good 
health for some months. The other case is improving, having gained six 
pounds in weight during the last month j cod-liver oil, with quinine and iodide 
of iron, has been the remedy used. It is an interesting fact that in neither 
of these cases was any marked symptom of bronchial irritation present, and 
I believe the exciting cause of the disease had, in each case, been improper 
diet, or living too long on salt meat, which probably was rancid. A better 
diet was ordered, and strictly adhered to ; and it is the advantages derived 
from this, and also from the complete absence of any source of bronchial irri- 
tation, that have rendered the disease so amenable to treatment. Many cases 
prove fatal, as well here as elsewhere; but I believe that the climate of this 
country presents advantages such as are not to be found in any other part of 
the civilized world, for the treatment of phthisis in its earlier stages. 

The diseases arising from malaria might be expected to be very prevalent 
in the valley of the Sacramento, containing, as it does, thousands of acres of 
lands subject to annual overflow, and from which there is no escape for 
the water except by the slow process of evaporation under the rays of an in- 
tensely hot sun; yet, notwithstanding this, cases of intermittent and remit- 
tent fever are comparatively rare in this part of the valley. A few mild cases 
of intermittent fever occurred in the neighbourhood of the city last spring, 
but they appeared to be confined to low localities which were situated in the 
immediate vicinity of stagnant water. I have heard of but two cases of con- 
gestive- fever, and both of them on low bottoms near the American Biver, 
about three miles from the city. As a general rule, the city is exempt from 
any of the more violent forms of malarious disease; a few mild cases of inter- 
mittent and remittent fevers occur, but they are comparatively rare. The 
whole number of cases admitted into the hospital in this city, which originated 
in Sacramento, was twelve during the last summer and autumn. But, although 
the influence of malaria does not show itself by producing any of the more 
marked forms of disease by which its presence is usually manifested, yet we 
have constant indications of its existence, by the character it impresses on 
almost every form of disease occurring in this locality. It would appear that, 
when in the usual state of health, there are very few individuals in the com- 
munity who are susceptible to its influence, but when the resisting powers 
become weakened by any form of disease, the malarious influence then makes 
itself felt, modifying to a greater or less extent a very large amount of the 
cases of other diseases. This influence it is often difficult to detect; it is not 
manifested by any marked symptoms of intermission or even remission, but 
can only be suspected from the apparent obstinacy of the disease, and from 
the effect of treatment. Dysentery, diarrhoea, erysipelas, rheumatism, chronic 
gastritis, and even pyrosis, cases in which the remedy might appear to be 
strongly counterindicated, were benefited by the use of quinine, and, in fact, 
would not yield without it. This modified existence of malaiia, in a locality 
No. XL VII. — July, 1852. 5 



62 Blake, Climate and Diseases of California. [July, 

where the elements from which it is generated surround us on every side, 
is probably to be accounted for by the dryness of the atmosphere during the 
hottest months in the year; to the moderate temperature that generally pre- 
vails when the amount of humidity in the atmosphere would favour its propa- 
gation or diffusion; to the prevalence of constant breezes during the summer 
months; and to the coolness of the nights, which conduces to refreshing and 
invigorating sleep. 

As regards the number of cases of bilious remittent reported to have been 
admitted into the hospital, I believe they were for the most part cases of the 
mildest form of remittent fever. I understand from many medical gentlemen 
who practised here during the summer, that they did not see a single case of 
bilious remittent, and the short time the patients remained in the hospital (on 
an average eight days)* would indicate a very mild form of remittent fever. 
From the most accurate information I could acquire (for no records are kept), 
the greater number of the cases came in from the upper part of the valley, 
more particularly above Marysville. Scrofulous diseases are rarely met with, 
and I believe the climate will be found to offer the most favourable conditions 
for the prevention and cure of this class of diseases. 

Diseases of the skin are rare; eczema is the only one I have met with. 
Onychia is common among the mining population, and slight wounds on the 
hands are very apt to prove troublesome; this is probably owing to the nature 
of the diet, for even when wholesome articles of food can be obtained, they are 
generally spoiled by boiling them in rancid grease. The quantity of rancid 
grease and salt meat eaten in this country with apparent impunity offers but 
a poor confirmation of the views of Liebig, of the injurious effects of partially 
decomposed substances on the animal economy. 

Diseases of the nervous system are not very common, although I believe 
forming a larger proportion in comparison to the whole amount of disease than 
in the Atlantic States. A very large number of cases of insanity have oc- 
curred, thirty-eight insane patients having been received into the hospital 
from May to December. This prevalence of insanity is undoubtedly owing 
to moral more than to physical causes, although the extreme dryness of the 
atmosphere during the summer undoubtedly renders the nervous system pe- 
culiarly excitable. There is one fact with which I have been struck whilst 
travelling in the mountains during the last summer; viz., the rare occurrence 
of covp-de-soleil. It might be supposed that the miners would be peculiarly 
liable to this disease, exposed as they are for hours to the burning rays of the 
sun, and frequently with their feet in ice-cold water; yet I have never seen 
or even heard of an instance of sun-stroke, although the rays of the sun are 
certainly more powerful here than in most of the Atlantic States. 

* In drawing up this average, three cases were excepted in which the patients re- 
mained in the hospital thirty seven, fifty, and sixty-four days, and in which there was 
undoubtedly some complication. 



1852.] 



Blake, Climate and Diseases of California. 



63 



The climate in the mining regions very much resembles that of the valley, 
and it is necessary to ascend some distance in the mountains before any 
marked difference is noted, even in the temperature. I have no correct data 
on this point, but the state of vegetation would indicate that there cannot be 
much difference in the temperature. When I left Placerville (about sixty miles 
south of Sacramento), three weeks since, or in the middle of February, the 
young shoots of the buckeye were three inches long. The masoneeta (a spe- 
cies of erica) was in full bloom. The humming birds were building their 
nests, and I believe vegetation was quite as forward, and, perhaps, more for- 
ward than in the valley. This was at an elevation of two or three thousand 
feet above the valley. 

The mining regions are generally extremely healthy, with the exception of 
those localities which are situated in deep valleys surrounded on every side 
by high hills. Here the extremes of temperature are very great. As a gene- 
ral thing, the nights in summer are calm, and the great radiation that takes 
place under a perfectly clear sky rapidly cools the layer of air in direct con- 
tact with the ground. This cold air can be felt running down every gulley 
and ravine leading into these deep hollows, and if there is not any large open- 
ing by which it can drain off, it accumulates and fills the valley with a body 
of dense, stagnant air, the temperature of which descends very low before 
morning. In such places, typhus fever and erysipelas were very prevalent 
during last summer, and were also very fatal. With this exception, the 
mountain regions are very healthy ; and it is a striking fact, in confirmation of 
this, that exposure can be borne here to almost any extent with impunity. 
During ten months in the year, the shelter of a tree is all that is required. 
When travelling in the mountains, I always slept in the open air except when 
it rained, and I never experienced the slightest inconvenience from so doing ; 
nor have I ever seen any instance in which bad results followed, except in 
wet weather. This is very different from what we are taught to believe as 
regards exposure to the night air in the Atlantic States, with how much rea- 
son I cannot pretend to say, never having there tried the experiment. The 
general health of the community is, I believe, of a higher character than in any 
other part of the Union ; the complexion here generally assumes that ruddy 
tint which is considered, and I think justly, as the most unequivocal sign of 
a high state of health in individuals of the Anglo-Saxon race. A residence 
of a few months in the country is almost always accompanied by a marked 
increase in weight, and there can be no doubt but that the climate is con- 
ducive to fertility in the female. Although I may expose myself to the 
charge of enthusiasm as regards the climate of this country, yet I am but 
expressing my candid opinion when I state that I believe California will be 
found more conducive to the highest physical and intellectual development 
of the Anglo-Saxon race, than any other part of the globe. There is not a 
day in the year in which the powers of the mind or of the body are enervated 



64 



Frick, Case of Saccharine Diabetes. 



[July, 



by heat or numbed by cold. And when the agricultural resources of the 
country shall become developed, and the swamp lands reclaimed and brought 
under cultivation, I believe that every external influence, detrimental to the 
preservation of health, will be reduced to a minimum. 



Table showing the number of cases of the principal diseases admitted into the 
State Hospital, Sacramento City, with their average mortality and dura- 
tion of treatment. 





June. 


1-5 


August. 


September. 


October. 


November. 


December. 


x3 
o 


Number of 
deaths. Per 
cent. 


Average 
time of 
treatment. 


Number of 
cases in 
Sacramento. 


Intermittent fever .... 




6 


6 


11 


12 


4 


6 


45 


1.2 


7 dys 

8 


5 


Bilious remittent fever . 


4 


6 


21 


21 


38 


18 


8 


116 


4.3 


6 


Congestive fever .... 




2 




2 








4 


50.0 


6 


1 


Typhus fever 






1 


4 


12 


5 


11 


33 


39 7 


13 


3 


Continued fever .... 


3 


2 


2 




1 


2 




10 




9 


1 


Erysipelas 






1 


4 


3 


1 


2 


11 


18.1 


7 




Diarrhoea . . 


3 


1 




1 


1 


3 




9 








Chronic diarrhoea .... 


4 


3 


2 


3 


5 


3 


1 


21 








Dysentery 


2 


1 


1 




1 


2 


6 


13 


56 






Acute bronchitis .... 












3 




3 


54 






Chronic bronchitis .... 


1 




2 




1 






4 








Pneumonia 














5 


5 


100 






Pleurisy 


1 










1 




2 








Acute rheumatism 


9 


3 


o 










14 








Chronic rheumatism 


3 


2 


5 




4 




2 


23 









Sacramento City, March 14, 1852. 



Art. V. — A Case of Saccharine Diabetes, with Tabular Observations of its 
Pathology, and the Results of Treatment. By Charles Frick, M. D., 
Baltimore. 

The following case of saccharine diabetes has been under my care, in the 
Maryland Penitentiary, for the past ten months. From the particular advan- 
tages for medical observation to be obtained in an institution of this character, 
inasmuch as the amount of exercise, diet, and labour is nearly equal from 
day to day, I have had better opportunities for obtaining comparative results, 
and am enabled to state more facts, in relation to this particular case, than 
could be ascertained elsewhere. And although I have not been able to deduce 
any explanation of the pathology of this disease which is much in advance of 
the theories which at present prevail, yet I feel assured that I am enabled, on 
the one side, to substantiate beyond doubt many of the facts recorded by 
previous observers, and on the other to settle definitely one or two disputed 
points. I should moreover state, at the commencement, that the quantity of 



1852.] Frick, Case of Saccharine Diabetes. 65 



ingesta and egesta, as recorded in the tables, I am satisfied, is strictly correct, 
and whenever I had reason to suspect the least inaccuracy the observation 
was thrown aside as worthless. 

Nicholas Matthews, mulatto, set. 37 years, height six feet three inches, 
weight 180 lbs., entered the prison March 23, 1851, under a sentence of nine 
years. He is not fleshy, but strong and healthy in appearance. Previous to 
his confinement, he lived in the country, near the village of Ellicott's Mills. 
The soil is of granitic formation, and he worked most of his life in the open 
air as a stonecutter. His health, for the last nine years, has been so good 
that, during that time, he has not lost a day from sickness, and was enabled 
to do as full a task as any one working at the same occupation. Nine years 
ago he was treated for a pleurisy on the right side, which confined him to the 
house for two weeks, and he has, at this time, slight dulness on percussion 
on that side, from old false membranes. He has always been well fed and 
clothed, and has been a temperate man, for the last nine years having not 
once tasted ardent spirits. His diet consisted of vegetables, meat, and bread, 
and neither his appetite nor thirst could be considered inordinate. The meat 
was almost always salt, and the bread contained no yeast, he having ascer- 
tained that ordinary fermented bread was apt to occasion pain in his bowels. 
He says that his father had something like diabetes at the age of forty ; but 
it passed off in a few years, and he is now alive at the age of eighty-four. 
None of his relatives died of phthisis. One brother, aged fifty-eight, is at 
present an inmate of the prison, sound and well in every respect, and another 
he lost from pneumonia. He had never noticed anything wrong about his 
urine, and is confident that he never passed any unusual amount before his 
confinement. About a year since, he remarked, for the first time, that he had 
occasion to rise once at night to empty his bladder. This has continued ever 
since. After the attack of pleurisy, he had attracted attention among his 
fellow-workmen from the fact of his excessive perspiration. Since his resi- 
dence in the prison, his skin has been dry except in hot weather. For some 
years he has been subject to pain across the loins, and occasional cramps in 
the solei muscles. But these he attributes to an inguinal hernia which was 
produced about that time. The day of his entrance he was placed in the 
spinning-shop, where he continued for five weeks at work, when my attention 
was attracted to him. He had lost twelve pounds in weight, complained of 
great weakness in his knees, and inordinate appetite and thirst. This latter, 
he stated, had been so great that in the dormitory, where he could procure no 
water, he had drunk his own urine, which he described as being sweet to the taste. 
On testing it, I found it distinctly saccharine. He was then removed to the 
hospital for more accurate observation, and for three weeks was subjected to 
different kinds of diet without remedial treatment; every article of food eaten, 
and the exact quantity of urine discharged, being ascertained throughout the 
whole period. I ascertained that his lungs and heart were perfectly sound. 
There was no pain in his head, neck, or along the spinal cord, with or without 
pressure. The liver and spleen are of natural size, and all the abdominal 
organs, as far as I can discover, are in a normal condition. His health now 
is about as good as at entrance. At different periods of his confinement, I 
have examined the following fluids of his body for sugar. The test most 
commonly used was the addition of liquor potassas and sulphate of copper, 
known as Trommer's. I also used Moore's test, the Barreswil liquid, yeast, 
and nitrate of silver. Of these, Barreswil's liquid gives the most satisfac- 



66 



Frick, Case of Saccharine Diabetes. 



tory results, provided the quantity added before heating be equal at least to 
one-third or one-fourth the quantity of urine.* 

The urine was examined repeatedly, and always contained sugar, the amount 
holding a definite relation to the specific gravity. 

The sweat was examined several times. Half a drachm collected by a 
spoon from his skin always gave the characteristic reaction. 

An infusion made by pouring boiling water on the feces, filtering, and then 
boiling with animal charcoal to decolorize, always contained sugar. The 
largest quantity was obtained from the stools passed during an attack of 
cholera morbus. 

On treating the contents of his stomach in the same way, whether ejected 
by cholera morbus or by an emetic, the characteristic reaction was always made 
evident. This was most marked in the matters thrown up a few hours after 
a meal, and was present when the diet consisted of meat and eggs alone. I 
think we may account for it in this case, by its presence in the mucus and 
gastric juice ejected at the same time. 

While labouring under catarrh, the mucous expectoration from his bronchial 
tubes, on being diluted with water, gave the characteristic reaction. 

This was also the case with the saliva, in every instance that I examined 
it. Bernard states that true saliva in this disease contains no sugar ; but, as I 
was unable to separate the secretion obtained from the parotid and sublingual 
glands, and the buccal mucous membrane, I cannot assert that he is mistaken. 

Blood was taken from him, in two instances, by cups. At both times it 
contained sugar, and gave the characteristic reaction in a more marked degree 
than any of the fluids examined. Its detection was very simple. About half 
a drachm of serum was diluted with half an ounce of water. This was heated 
to coagulate the albumen, filtered, and the test applied to the filtered fluid. Or, 
an ounce of blood was dried, pulverized, and alcohol poured on it. This was 
filtered and evaporated at a gentle heat; then dissolved in water. Only a 
few drops of this solution were necessary to indicate the presence of sugar. 

From an abscess of the hand half a drachm of pus was collected. This was 
diluted, boiled, and filtered. The usual test gave the characteristic reaction.^ 

It is thus shown that all the secretions of his body which were available for 
examination indicated most decidedly the presence of sugar, and this without 
any relation to the diet, although the reaction was most marked when sugar 
or starch was used as food. 

* The composition of the Barresvvil fluid, for which I am indebted to Dr. Donaldson, 
is as follows : — 

R. Crystallized carbonate of soda gj, ; 

Caustic potash gij, ^ij; 

Bitartrate of potash gj, Qij; 

Sulphate of copper ; 

Distilied water Oj. 
M. To be boiled, and then filtered. 

f I am aware that the reduction of the oxide of copper may be produced by other 
organic substances besides sugar, and that from the presence of albumen false inferences 
may be drawn. Such, I am satisfied, is not the case in the present instance. 



1852.] 



Eiiek ; Case of Saccharine Diabetes. 



67 



6> 



03 

pi 

M 


Weighs, to-day, 168 lbs. 
,^,ij of sweat collected; con- 
tains sugar. 

Mucus from bronchial tubes 
contains sugar. 

Weiglis, to-day, 168 lbs. 
Yesterday's stools contain 
sugar in abundance. 

Detected sugar in swoat to-day. 

Weighs, to-day, 162 lbs. 
Sugar produced nausea, but no 
vomiting. 

Weighs, to-day, 163J lbs. 


•U0T1-Blldsi3(j 


Moderate 

Profuse 

Profuse 

Profuse 
Considerable 

Considerable 
Scanty 
None 
None 

None 

Moderate 

None 

Moderate 

None 

None 
None 
None 
None 
None 
None 
None 




COOOtoO CO O CD © mod 

g~g §5 <No*=-g = g — «M — g § 


H 
«! 

« 
O 
O 


•saoano nt 
£ JBSn S 


* 

* 


•saonno nt 

'T3UIJEJ AJ(I 




•saonno ni 
£ paaua:iiJ3jnn 
'peaig 


C O 05 
CO CO CO 


■saonno nt 
'pajnauijaj 
'pnajg 


CD CO CD O O GO CO 

CO CO * * 


•saonno 
m £ iBai\r 


CD CD CD CD O COCO-* "* <N <N CD CO CO 
~ — — — CM — — CM C} CO CO — < — — i 


•sSS a 


CD OO CD MO CO CD CO COCOOCO 




•saonno ui 
£ jinB.ip Bajj 


OOO OO Ci 00 oo o o o o o 2 
COCOCO COCO O iQ CO CD X N N J} ?! ; - 


•saonno nt 
£ aueip jajBAV 


£-rrco c w co * o t- o * co o o cocooo— ' 
co o o -ir- o oo co o in c a c: n o co * co 

— ^-4 — — — — r-« CN —1 — 1 r-iCM 


•saonno ui 
£ pooj ui pauiBjuoo 
iB§ns jo AjuuBnfr 


OO* * * _ O O „, _ „, O O O O CD CD CO CM CM 

* * * * * cc -ot- « 2 ^OiO o >o CO CO 
nr •>* i> t- r- ==^rco - - - ■* oo co * ac ac oc * * 

— — CO COCO £ ^ " uT.Tu^'-'O O * C~ I- OO CO 

£ £ £ £ £ <N „^^^„«^ 


•saonno ni 'sAan 
-pijf uiojj passed 
jeSns jo A:mnen£) 


cm to eo o cot- co o> co * io id oo oi o o x « c - c « 

CM CD 00 CO tN * O CO CO CO CM CM OC CO O CO OC CO CO CO O CD 
IQiOOrf OO CM CO CM CO C) CO C iC 7) O 00 00 * CO — 1 

co « w ci otp i—. cm co cm oo oc o x £> t- 


■anun jo 
A^iAeaS ouroadg 


cocococo coo co — * co * * — o * co co * o co o 

CO.—! — CO COCO CNWN CM CO CO CO cococococococo 

oooo oo oooo coooo ooooooo 


•saonno 
ni £ jpiBip pinjj 


CI* CO iO CO CO * 00 O iO * CO O O CO CO O O — 

o — co j>r- o oo co co cm o co o co o. oc co o 

(NC!« — — — — — — — CO CM CM — CM CO 


•sanoq ni saoano 
ui passed ainJjl 


— o -s" o co o co c w to co co * co -*r * — o oc — •* c<» 

X C O Q OCO t? f C X O CO X CO f CO O CO CM CN CO ia 

■? N O! - — — — — co cn cm — <n co cm cm 


•Asp jo jnojj 




H 
E-" 

<! 

a 


CN 

o 

00 

XOO- O? CO * O CD t- 00C1O - CM MTfOtOi- -^CN 



6S 



Frick, Case of Saccharine Diabetes. 



An examination of the preceding table allows us to make the following 
deductions : — 

In the first place, that the quantity of urine is in itself no measure of the 
extent of the disease, it being regulated by the quantity of fluid drank, the 
perspiration, the number of fecal evacuations, &c. That in no instance was 
the quantity of urine passed greater than the amount of fluid drank, although 
a writer in the October number of the Archives Genirales de Paris, assuming 
that the contrary was always the case, has endeavoured to prove that in dia- 
betes a portion of the water in the renal secretion is produced by the union 
of hydrogen and oxygen within the body. On comparing the two columns 
of fluid drank and fluid passed, which I have placed side by side for better 
comparison, it will be seen that the relation between the two is very exact, 
and becomes more or less disturbed in proportion to the number of stools and 
the profuseness of the perspiration. 

The quantity of sugar, although in a great measure dependent upon, is not 
always in proportion to, the amount of urine passed. A certain quantity of 
sugar is to be eliminated by the kidneys, and a proportionate amount of water 
is necessary for its solution. This want is intimated to the sensorium which 
seeks to supply it, just as a farther supply of material for carrying on the 
functions of the animal body is intimated by the sensation of hunger. And 
I ascertained, in the case of the patient under consideration, that when he 
was made to driDk more or less fluid than he desired, the quantity of sugar 
remained the same, the specific gravity of the urine only undergoing altera- 
tion. For this reason he was allowed to drink an unlimited quantity of water, 
so that he rarely complained of thirst. In calculating the amount of sugar in 
his urine and food, I do not pretend to have been perfectly accurate; but, as 
my object was to obtain facts which would enable me to institute comparative 
results, I feel assured the mode of proceeding has been sufficiently exact. The 
quantity of urine, and the specific gravity at each period of voiding it, were 
accurately determined, and the amount of solids calculated by the ordinary 
table. I had previously ascertained from analysis that the usual healthy in- 
gredients were all present in about their normal quantity, and as these vary, in 
a healthy individual, from 600 to 700 grains in twenty-four hours, I assumed 
them to be 650 grains, which amount was deducted from the whole solids, 
and the remainder considered as sugar. The quantity of this substance in 
the food was ascertained by taking the analysis of the different articles of diet, 
as laid down by different authorities, and estimating the quantity of sugar, 
and of substances capable of forming it, in each separately. 

On comparing these two results, it will be seen that, although on five days 
no sugar or those substances capable of forming it were taken as food, yet, 
nevertheless, an average of 707 grains was passed each day from the kidneys; 
thus establishing the fact, previously stated by Bernard, that the source of 
the sugar is due to some cause beyond the non-conversion of the saccharine 
and amylaceous elements of food. Taking this fact into consideration, it is 
shown that the additional proportion of these substances, as diet, influences 
directly the quantity of sugar excreted. And whether the food consists of 
sugar alone, or a combination of sugar and starch, the result is nearly the 
same. Thus taking into consideration the quantity contained in the fecal 
discharges, on forty-four ounces of pure sugar the same proportionate amount 
was excreted as on thirty ounces of leavened, or thirty-nine ounces of un- 
leavened bread. 

I have arranged the following table to show the aggregate and average 



1852.] Frick, Case of Saccharine Diabetes. 69 



amounts of sugar and urine passed between the different hours of the day, for 
fifteen days, at various intervals : — 



Hour of day. 


Aggregate 
quantity 
of sugar, 
in grains. 


Average 
quantity 
of sugar for 
each day. 


Aggregate 
quantity 
of urine, 

in ounces. 


A verage 
quantity of 
urine for each 
day. 




7 tn 8PM 


4329 


2S8 


145 


10 




S tn Q 
o io y 


5356 


357 


1 86 


1 9 




9 to 10 


5434 


362 


194 


1 "3 

ID 




10 to 1 ] 


7019 


468 


229 


15 




1 1 to 12 


1008 


£7 


48 


3 




12 to 1 


6119 


408 


175 


12 




1 to 2 


1590 










2 to 3 


3477 


232 


110 


7 




3 to 4 


3924 


9fi9 


122 


3 






2468 


J. u^fc 


68 


4 




5 to 6 


3426 


228 


104 


7 






24 3 S 


lOo 


7 J_ 


5 


Dreakicist. 


7 tn 8 A AT 


1836 




54 






8 to 9 


1754 


1 1 7 


55 


4 




9 to 10 


2548 


169 


82 


6 




10 to 11 


6924 


462 


209 


14 




11 to 12 


4312 


287 


133 


9 


Dinner at 12. 


12 to 1 


5047 


336 


154 


10 




1 to 2 


6597 


439 


197 


13 




2 to 3 


6459 


436 


219 


15 




3 to 4 


8636 


576 


301 


20 




4 to 5 


9622 


630 


338 


25 




5 to 6 


9154 


610 


298 


19 




6 to 7 


6545 


436 


214 


14 


Supper. 






7741 | 


253 



It will be seen, on reference to the preceding table, that during the seven 
hours occurring between twelve and seven o'olock, or those immediately after 
the ingestion of the principal meal, and under various modes of treatment, 
the average quantity of sugar passed is 3459 grains, or very nearly one-half 
of the whole amount. And, moreover, that the same is true in regard to the 
quantity of urine, 116 ounces having been voided in the same interval of 
time. Another interesting fact is also here exhibited. After each meal, 
both the quantity of sugar and of urine commences and goes on to increase 
in regular progression up to the fourth hour, when it again decreases in nearly 
the same proportion. This table is made up of one hundred and forty-four 
separate observations, and the average specific gravity of the urine for the 
whole number is 1.0305. 

A quantitative analysis of the amount of urea was made on three separate 
occasions. The mode of proceeding was to evaporate the urine over a water- 
bath to about one-fourth its bulk. From thirty to forty ounces were used for 
this purpose, and the urea was obtained in the form of a nitrate or an oxalate. 
It amounted to 90.56 grs., 102 grs., and 121.6 grs., respectively. We will 
not undertake to say that all the urea contained in the specimen examined was 
thus obtained, and shall, therefore, draw no conclusions from its deficiency. 



70 Frick 7 Case of Saccharine Diabetes. [July? 

Table showing the comparative Effects of Treatment for 9 months continuously 



Date. 


Quantity of 
urine in 24 hours, 
in ounces. 


Quantity of sugar 
in urine in 24 
hours, in grains. | 


June 1 


313 


11657 


" 8 


401 


11380, 


" 16 


358 


9000 


<< 22 


440 


14960 


July 12 


342 


9950 


" 20 


278 


7134 


" 25 


136 


3830 


<< 23 


78 


2000; 


Aug. 18 


150 


3550 

1 


" 22 


184 


5520 


Sept. 7 


200 


4070 


<< 15 


90 


2500 


" 21 


63 


867 


" 29 


247 


8000 


Oct. 5 


177 


4964 


" 12 


187 


4630 


" 19 


116 


2688 


» 22 


40 


1000 


" 24 


39 


689 


" 25 


43 


1017 


Nov. 2 


90 


2467 


" 9 


103 


2037 


" 16 


223 


5264 


<< 21 


267 


6927 


" 30 


486 


13728 


Dec. 7 


442 


12336 


a 14 


572 


15192 


" 21 


515 


15784 


" 28 


648 


16708 


Jan. 3 


612 


18972 


" 8 


648 


19438 


" 13 


206 


4836 


" 20 


172 


2364 


" 29 


522 


16704 


Feb. 15 


520 


19030 


" 22 


420 


11950 


March 1 


703 


20440 


" 4 


322 


13860 



Medicine taken during 
the day and the week 
previous. 



19200 None 

19200' Cod-liver oil, 9.5 per week 
192001 Cod-liver oil, 73 per week 
19200;Cod-liver oil, 20;? per week 
19200j Cod-liver oil, 103 per week ; 

aqua ammonia, 5 drops 3 

times daily 
20000,1- 20th gr. of strychnine, 3 

I times daily 
19800| Strychnine, the same 

18200, l-15th gr. of strychnine, 3 
times daily; 93 cod-liver 
I oil per week 
22000 Strychnine and cod-liver oil, 

the same 
21500 Strychnine l-20th gr. 3 times 
daily 

21950 Strychnine l-10th gr. 3 times 
daily 

20080 Strychnine l-7th gr. 3 times 
daily 



daily 
18100 None 

24400 Strychnine l-12thgr. 3 tim 
daily 

23200 Strychnine l-7th gr. 3 times 
daily; cod-liver oil 103 per 
week 

24200 Strychnine l-6th gr. 3 times 
daily ; oil, the same 

No None 
food 

920 None 
4520 Strychnine l-6th gr. 3 times 
daily 

26300 Strychnine, the same 
36000 Mur. tine, ferri 10 drops, 3 

times daily 
36000 Mur. tine, ferri 20 drops, 3 

times daily 
36000 Iod. potass. 3 ars. 3 times 
daily 

36000 Creosote 1 drop ; naphtha 10 

drops, 3 times daily 
19100 Cod-liver oil, 83 per week 
1000 Cod-liver oil, 6.3 per week 
21000 Cod-liver oil, 63 per week 
21200 Cod-liver oil, 113 per week 
22000 Whiskey, 33 daily 



21000 Whiskey, 33 daily 
21000 Strychnine l-9th gr. 3 times 
daily 

Strychnine l-6th gr. 3 times 
daily 
23300 None 

23300 Calomel 1 gr. ; opium 1| gr. 
once daily 

21200 Ergot 3 grs. 3 times daily 



26000 Ergot 3 grs.; iod. ferri 2 gi 

strychnine l-10th gr., 3 
times daily 
25500 None 



© P 
© B 



2 

4 loose 



4 loose 



3 loose 
1 



3 loose 

2 loose 

5 loose 

1 

3 
1 
2 
3 
1 



©03 

m 



165% 

170 

166% 

170% 

173 



170% 
170% 



Remarks. 



Diarrhoea last week 

Gained 7% lbs. on 563 
cod-liver oil in 42 
days. 

Pus from hand con- 
tains sugar. 

Slight diarrhoea stools 
contain sugar. 

In hospital for diar- 
rhoea. 



170% Has taken in 20 days 
323 of cod-liver oil. 



Medicine has produced 
stiffness of neck, and 
increase of venereal 
desire. 
Only 303 were passed 
m first 18 hours. 

162 
157% 

161% 



165 

162 

166 

164% 
160% 



167 

167 

168 

169% 

172 



170 
170 

169% 

168 
171 



180% 



171 



Has gained 7% lbs. on 
203 cod-liver oil in 2 
weeks. 

Sools equal 1 gallon ; 
contains sugar. 



Detected iodine in 

urine. 
Medicine produces 

great discomfort. 



Has taken 403 of cod- 
liver oil in 30 days, 
and gained 11% lbs. 



Taking this for 2 

weeks; rises 4 times 

each night. 
Says he is getting 

well ; rises but once 

at niarht. 



1852.] 



Frick, Case of Saccharine Diabetes. 



71 



Inasmuch as it is only of late years that we can conclude with certainty that 
the cases reported as diabetes were in reality that disease, we must take with 
considerable reservation the many accounts of their successful treatment. In 
the second case here reported, the patient believes himself cured, and looks to 
be in perfect health; but he is still passing from four to five ounces of sugar 
from his kidneys daily. And it is certain that, latterly, the journals less 
frequently contain reports of cases of this disease treated successfully. Of 
the ten or twelve that have fallen under my observation, most of them 
through the kindness of my friends, not one, so far as I know, has ever re- 
covered. 

We will now examine, in detail, the effects of treatment in this case. 
Each medicine was continued for at least one week, and the urine examined 
at the end of that period. It is impossible to make any exact comparison of 
these various modes, unless we could ascertain the amount of sugar passed 
in the stools and from the skin, as well as from the kidneys. And an exami- 
nation of the preceding table will convince any one that an estimation of the 
increase or diminution of sugar in the urine is valueless unless, at the same 
time, allowance be made for the quantity passed in the fecal evacuations. The 
amount contained in the sweat we are forced to omit; but, as the condition of 
the skin remained nearly the same during the time the patient was under 
treatment, particularly for the last four months, we can the more readily 
afford to throw this element out of consideration. We endeavoured to ascer- 
tain accurately the amount of sugar contained in the stools, but with little 
success. There were, however, periods when he was kept, as nearly as possi- 
ble, from day to day, under the same conditions, both as regards diet, exercise, 
and medicine; and we then remarked that, when the stools were about the 
same in number and quantity, the amount of sugar contained in the urine 
varied very little, but was increased or diminished in proportion to the fecal 
evacuations. From this fact, and one or two rough analyses of the fecal 
matters, we estimated the average amount of sugar in each stool to be about 
1300 grains, and we shall assume this quantity in considering the effects of 
the different remedies. Whether this 1300 grains be too large or too small, 
the proportionate amounts remain nearly the same, and we subjoin below a 
comparative table of the different quantities of sugar passed from the kidneys 
and bowels together, while under the influence of the above remedies. 



Strychnine 



Mur 



tine, ferri 



Aqua ammonia 
Iod. potass. 



* gr. 

7 gr. 

to gr. 

tV g r - 

2*n gr. 

10 drops 
20 " 

5 " 

3 gr. 



Grains. 

3369 
3565 
6250 
6425 
6360 
6900 
8264 
12550 
14270 



Grains. 

Without medicine 14520 
Creosote and naphtha 15028 
Cod-liver oil, 6§ per week 15058 
10J per week 16108 
Pulv. ergot . 17150 

Cod-liver oil, 2O5 per week 20160 
Whiskey . 20504 

Calomel and opium 24230 
Ergot, strychnine and iron 24340 



Strychnine. — The amount passed without medicine is obtained from the 



72 Frick, Case of Saccharine Diabetes. [J u ty; 

average of eleven analyses. We see, therefore, that the influence of strych- 
nine exerts by far the greatest control over the quantity of sugar passed in 
the urine and feces. The patient was kept under its influence for various 
periods, amounting in all to four months. It is here shown that, under doses 
of one-twentieth of a grain, the amount is diminished to less than one-half, 
and under one-sixth of a grain to less than one-fourth. For three successive 
days he was kept upon a meat diet, and one-sixth of a grain of strychnine 
administered three times daily. The quantity of sugar, on the third day, was 
diminished to 132 grains. This was on the 30th of October, and was the 
smallest quantity we ever found in this patient's urine. 

Mur. Tine. Ferri. — This remedy, in doses of ten drops, diminished the 
sugar one-half ; but on increasing the dose to twenty drops, a notable increase 
manifested itself, though still showing the beneficial effects of the medicine. 

Aqua Ammonia. — The diminution here amounted to one-seventh. Larger 
doses were tried, but they produced so much uneasiness that they had to be 
discontinued. 

Iodide of Potass. — The effect of this remedy over the excretion of sugar 
was little or none. It produced pain in the bowels and diarrhoea. 

Creosote and Naphtha. — These also produced great inconvenience, and their 
effect was to increase slightly the quantity of sugar. 

Cod-liver Oil. — In whatever doses this medicine was administered, its effect 
was to increase the amount of sugar. When six ounces per week were taken, 
the difference was slight ; but when increased to twenty, one-third more sugar 
was passed. One fact, however, is worthy of notice. The patient, under 
this remedy, always gained weight, and, with the exception of the period when 
ergot was administered, only at that time. In forty-four days, on four pounds 
of oil, he gained nineteen pounds. 

Pulv. Ergot. — The patient, under the influence of this remedy, gained in 
one week nine and a half pounds, but the amount of sugar increased one- 
sixth. 

Whiskey. — This increased greatly the quantity of urine, as might be sup- 
posed, and also the sugar, which amounted to one-third more than when he 
was taking no medicine. 

Calomel and Opium. — This was continued for two weeks, till the patient 
was brought decidedly under the influence of the mercury. The calls to 
urinate became more frequent, and the amount of sugar became nearly 
doubled. 

Ergot, Strychnine, and Iod. Ferri. — Under this combination, the excretion 
of sugar was about the same as the preceding. He complained greatly of 
the mixture, and it will be seen that the largest quantity of urine was passed 
by him at this time, amounting to forty-four pints. 

In concluding these remarks on the subject of treatment, we have seen that 
those remedies which act directly upon the nervous system exert by far the 
greatest power in lessening the amount of sugar in the secretions. And con- 



1852.] 



Frick, Case of Saccharine Diabetes. 



73 



sidering that the formation of this substance in the body was a natural process, 
and that our aim should be, not to prevent its formation, but to rouse up and 
strengthen the vital functions, in the course of whose normal action it is de- 
stroyed and eliminated from the system, we prescribed strychnine, and the 
result, in some measure, has justified our anticipations. It is needless to re- 
strict the patient to an animal diet, for, although the prominent symptoms ame- 
liorate under this treatment, the patient is not in reality better, and, in a 
majority of cases, the discomfort produced by the deprivation of saccharine 
and amylaceous food is not counterbalanced by the diminished thirst and the 
less frequent calls for micturition. 

Case II. — January 10, 1852. , a lawyer by occupation, and 

37 years of age; short, stout, and having every appearance of being in robust 
health; applied for treatment on account of suppuration in the internal and 
external ear. He had lived freely for many years, drinking, principally, whis- 
key, but was never sick in his life, except a slight attack, three years since, of 
what was called rheumatism, seated in his ankle and wrist. He has been 
discharging purulent matter from his ear for two weeks, which discharge had 
been preceded by intense pain and total deafness of that side. Leeches and 
antiphlogistic treatment generally were ordered. On the 19th of January 
he complained of some pain in the right instep, but there were no external 
evidences of disease. On the 20th, we found that the discharge from his ear 
had suddenly ceased, and that he heard a watch tick distinctly, at a distance 
of two feet, when the day previous he could only hear it when placed directly 
in contact with his ear. The pain in the instep had increased, and there were 
swelling and redness along the course of the tendons. On the 22d, gout in 
both feet was well declared. On the 24th, in both wrists, and the joints of 
both forefingers, so that he cannot walk or use his hands in the least. His 
intellect is somewhat disturbed at night, and he is sleepless, but there is no 
tremulousness. Ordered whiskey, Tarrant's aperient, and colchicum, the 
latter in doses of ten drops only. His urine, which previous to the attack 
had been high coloured and free from, albumen, was, at this time, pale 
and copious, and contained albumen in considerable quantity, but no sugar. 
On the 25th, disease the same, urine 1.035, albumen less in amount, no 
sugar. On the 26th, less albumen, but some evidences of sugar; for, 
when the albumen was coagulated and filtered from the urine, the residue 
gave a slight canary tint on heating it with Barreswil's liquid. On the 28th, 
disease subsiding, but urine contains sugar decidedly, as well as albumen, and, 
on standing for a few hours, throws down a copious deposit of uric acid sand. 
This is the first time this has been the case. On the 29th the albumen had 
disappeared entirely, and has not again made its appearance, but the sugar 
remained. The urine was of a greenish tinge, oily consistency, and strong 
saccharine odour, with a specific gravity of 1.036. 

Feb. 1. The swelling of the joints is subsiding, and he is walking about. 
Urine the same, sp. gr. 1.041, passes 150 ounces in twenty-four hours, con- 
taining nearly eleven ounces of sugar. 

4tth. Passing ten ounces of sugar daily from his kidneys. Ordered strych- 
nine and mur. tine, ferri. 

13th. Urine contains seven ounces of sugar. 

%4:th. Urine contains four ounces of sugar; medicine continued. 

29th. Urine contains five ounces of sugar. 



74 



Frick, Case of Saccharine Diabetes. 



Remarks. — T have reported the preceding case for many points of interest 
that it possesses. In the first place, it illustrates the early history of the disease. 
The association, at the commencement, with albumen, is probably accidental. 
The man's health was good till attacked by suppurative inflammation of the ear. 
The remedies for that affection prostrated his nervous system, and induced an 
attack of gout which he might otherwise have escaped. The albumen made 
its appearance in the urine from simple congestion and effusion from the kidneys, 
produced by their efforts to eliminate irritating materials. And these depress- 
ing causes united induced the presence of sugar in the urine in a patient, no 
doubt, already predisposed to diabetes. We believe this is the first case re- 
ported in which gout and diabetes have co-existed, and it is certainly an unusual 
event to observe uric acid crystals spontaneously deposited in saccharine urine. 

Pathology of the Disease. — It is only of late years that any insight has been 
obtained in regard to the morbid processes that take place in diabetes, and it 
is needless in these remarks to go into any review of the untenable grounds 
that were assumed to prove its location to be in the kidneys. Bouchardat, 
following up Rollo's suggestion of there being an abnormal principle in the 
gastric juice not found in the healthy state which acts upon the starch of the 
food and converts it into sugar, made a considerable advance, but he did not 
embrace the whole matter. Both McGregor and himself, as well as other 
observers, ascertained that the matters vomited by diabetic patients contained 
sugar, whereas in healthy digestion no such result ensued ; and they deduced, 
therefore, that the first step in the morbid chain started from the stomach. Had 
they examined all the available secretions of the same patient, they would have 
discovered that sugar was present in them all, for it is now well ascertained 
that in these cases it exists already formed in the gastric juice. For we ascer- 
tained, in the case here reported, that the presence of sugar may be very readily 
manifested in the matters vomited, when the previous meals consist of eggs 
and meat alone. Mialhe's theory, that diabetes is dependent on a neutral 
or acid state of the blood, needs only for refutation the fact that in every case 
of the disease where this fluid has been examined the reaction has been of its 
normal alkalinity, as we found it to be in the blood of the patient under con- 
sideration. 

In regard to Professor Graham's experiments in University College Hospital, 
he is evidently wrong when he states that "the quantity of saccharine matter 
in the urine never exceeds the starch and sugar in the food," On referring 
to the first table in this article, it will be seen that from May the 15th to the 
21st, a period of seven days, 2770 grains of sugar, or those substances capable 
of forming it, were taken as food, and then on the 16th and 17th only; and 
yet, 5765 grains, or more than double the quantity, were passed by the kidneys 
alone. This fact proves, what Bernard has already asserted, that sugar is 
eliminated by the kidneys even when none is taken into the stomach. And 
although Bouchardat and others are correct in stating that saccharine and 



1852.] 



Frick, Case of Saccharine Diabetes. 



75 



amylaceous food influence the amount of sugar in the urinary secretion, yet 
the fact stated above and supported by Bernard's previous experiments points 
to another, and in all probability a more important source for its production. 
In the July number of the American Journal, Dr. Donaldson, of Baltimore, 
has given in detail Bernard's experiments, proving the existence of sugar in 
the normal liver ; and has detailed his series of experiments on animals, proving 
that this substance may be produced at will in the urine. We will examine 
further on the light that these facts throw upon the disease under con- 
sideration. 

There can be no doubt that a portion of the sugar found in the various fluids 
and secretions of the body of a diabetic patient owes its origin to the amyla- 
ceous and saccharine elements of the food. "We know that in healthy diges- 
tion, the atom of starch which subserves merely the purposes of respiration, 
and can by no process be converted into any of the animal tissues, during its 
elimination from the body goes through the following changes : starch, dex- 
trine, sugar, vegetable acid, and carbonic acid. But from some stoppage in 
these changes the series is arrested at the sugar, which in this form is elimi- 
nated by the different excretory organs. What this arrest is, and where it is 
located, it is impossible in the present state of our knowledge to say, inasmuch 
as the only information we possess is the fact that when starch is taken into 
the stomach it is eliminated as carbonic acid and water; and we assume these 
intermediate stages to occur from knowing the changes that the same atom of 
starch would undergo out of the body. 

We have long known, from the researches of Dr. Bensch, that the milk 
of carnivorous animals, fed exclusively on flesh, contained sugar of milk ; and 
the announcement of the fact that the livers of the same animals kept on an 
animal diet, as well as those of the human subject living on ordinary food, also 
evidenced the presence of sugar, was not calculated to excite very great sur- 
prise. The fact, however, being now well established, we can no longer consider 
as tenable the idea so long inculcated, that animals had no power to create 
any organic principle found in their bodies, for it is here proved that sugar 
may be formed from nitrogenized materials. Bernard having ascertained that 
this substance existed normally in the right auricle of animals, traced it clown 
through the ascending cava and the hepatic veins to the liver, beyond which 
point he was unable to discover it. Now knowing the fact that, if a small 
quantity of sugar be added to some freshly drawn blood and exposed to the 
action of the air, the sugar disappears, we can readily understand how this 
substance, thus proved to exist in the healthy animal economy, can be con- 
sumed in the lungs, so that no trace of it is perceptible in the urine. Bernard 
furthermore ascertained that this sugar, like other secretions, was dependent 
upon the integrity of the nervous system, and that, by irritating the different 
nervous centres, which he ascertained generally produced an increased quantity, 
he occasionally found it completely suspended. This may explain why it is 



76 



Frick, Case of Saccharine Diabetes. 



[July 



that the urine of diabetic patients frequently loses its saccharine character a 
short time before death. 

It has been heretofore stated that the blood of the portal Tein contains much 
more fat than the hepatic, the proportion being as 3.2 to 1.9; and as a very 
close relation between the elements of sugar and cholalic acid, the principal 
organic ingredient of bile, with glycerine and fatty acid, which together con- 
stitute fat, can be readily shown to exist, it would seem very probable, as M. 
Schmidt, a German physiologist, suggests, that this extra amount of fat going 
to the liver, may be transformed into sugar, and thus account for the presence 
of this substance in that organ. Thus : — 

Fat acid + 14 oxygen = Cholalic acid + 8 water. 
C 4S H 47 3 + 14 oxygen = C 43 H 39 O g + 8 HO. 
2 eq. Glycerine + 4 oxygen = Sugar + 2 water. 
C M H 14 10 + 4 oxygen = QjtJ)„ + 2 HO. 

This would be very satisfactory; but, unfortunately in some respects for the 
theory, Bernard ascertained that this apparent excess of fat in the portal vein 
was due to regurgitation from the liver, where it is in reality formed; and 
that, if the portal vein be tied immediately on cutting through the abdominal 
parietes, instead of the fat being in excess, it will be found in less quantity 
than in the hepatic veins. 

But that a certain relation does exist between these two substances, and 
possibly after the mode above stated, there can be no doubt ; and the singular 
fact has been also stated by Bernard that, when the medulla oblongata is 
punctured, the amount of fat diminishes just in proportion as the sugar in- 
creases. In addition to this, M. Guillot states that, in diseases where there 
exists an interruption of the normal pulmonary circulation, such as is pro- 
duced in phthisis and pneumonia, there is a quantity of fat found in the lungs 
which does not exist in other diseases. This will probably explain the cause 
of the fatty liver so common in phthisis; for were this circulation not perma- 
nently embarrassed, the fat would be deposited in the cellular tissue, or con- 
sumed in the lungs; but as it is, these organs not ridding themselves of it, 
it first saturates them, and the remainder, as it is secreted, remains in the liver. 
Hence the emaciation, which is wholly due to the want of fatty matter in the 
cellular tissue, which occurs in phthisis. On the other hand, the lungs, in 
diabetes, contain little or no fat, but large quantities of sugar; and although 
emaciation is one of the most prominent symptoms of this disease, yet the 
cause is different from that which produces it in phthisis. In the latter case, 
it is from the accumulation of fat in the lungs and liver; while in diabetes it 
is from the fat undergoing excessive oxidation, and being thus changed into 
sugar. 

If, then, the facts just stated have any bearing, we are principally to explain 
the pathology of diabetes as being dependent on some derangement of the 
changes that ordinarily take place between the fat and sugar secxeted in the 



1852.] 



Erick, Case of Saccharine Diabetes. 



77 



liver. To assert what this derangement is, would lead us too far into the 
mazes of barren speculation. 

That the sugar produced by the liver should be consumed by the lungs, 
explains the connection between this disease and some pulmonary affections 
which are so often found to co-exist. Not that the one disease produces the 
other, but, when more than the usual amount of sugar is secreted daily by the 
liver, any accidental disease of the lungs, by interfering with their aerating 
power, prevents a certain amount of sugar from being consumed, and which 
must therefore be eliminated from the system without undergoing any change. 
That innumerable cases of diseases of the lungs occur without any connection 
with diabetes, and, moreover, that diabetes frequently takes place without any 
pulmonary complication, as in the two cases here reported, proves, without 
doubt, that deficient respiration, although occasionally acting as an exciting 
cause, bears, in reality, a very small part in occasioning saccharine urine; 
and that the presence of sugar in the secretions is not due to the fact of its 
being secreted in a normal amount by the liver, and remaining unconsumed 
in the lungs, but to its being formed originally in excess. Taking this view 
of the case, we should expect that the temperature of the body would not be 
diminished below that of a healthy man living on a diet excluding starch and 
sugar. And, in reality, such is the case in the present instance. The tem- 
perature of a man in full health, and that of one labouring under dysentery, 
were taken at the same time, by way of comparison. In the healthy man, 
the thermometer in the axilla stood at 98°, in the dysenteric patient 96°, 
while in the one labouring under diabetes it was 99°. 

A statement made by M. Regnoso, to the effect that he has found sugar in 
the urine of various persons labouring under acute and chronic affections which 
disappeared after convalescence, has been published in most of the journals 
within the past few months. I can only say, in reply, that of the many hun- 
dred cases in which I have examined the urine with a view of detecting sugar, 
I never found it in a single instance that was not, either at the time, or proved 
subsequently to be, a case of diabetes. Having control of a hospital averaging 
from ten to twelve patients, I examined, for the space of three months, the 
urine of each patient, during his sickness, with this very view, and in no in- 
stance did I ever detect sugar. 

In conclusion, then, to express in a few words the whole of our knowledge 
of the pathology of this disease, we say that in a state of health sugar is 
formed in the liver; that this sugar may be secreted when only azotized food 
is used; that in all probability it is formed from the fat which is also produced 
in this organ ; and that it is then conveyed by the blood, together with any 
sugar that may have been taken in as food, to the lungs, and there eliminated 
in the form of carbonic acid and water. That in diabetes, from some cause 
at present unknown to us, an unusual amount of this substance is formed by 
the liver, more than the lungs can dispose of, the surplus passing off by the 
different excretory and secretory organs ; and that although an amylaceous or 
No. XLVIL— July, 1852. 6 



78 



Morland, Extracts from Soc. for Med. Improvement. 



[July, 



saccharine diet increases the quantity, yet abstinence from these articles of 
food will not prevent it from making its appearance in the urine and other 
excretions. 

For many of the ideas herein stated we are indebted to M. Bernard, and 
we cannot but think that science is under great obligations to him for the 
satisfactory proofs he has given of the functions of the liver, so long a terra 
incognita to pathologists. Indeed, its importance as an organ of sanguifica- 
tion as well as depuration ought readily to be admitted, when we consider its 
large size in proportion to the rest of the body, and the complexity of its 
anatomical structure. 

Baltimore, March 7, 1852. 



Art. VI. — Extracts from the Records of the Boston Society for Medical 
Improvement. By Wm. W. Morland, M D., Secretary. 

January 12. — Angina Pectoris. — Dr. Jackson exhibited the heart taken 
from a patient whom he had recently examined, and showing extensive ossifi- 
cation of the coronary arteries, without any other change excepting an atrophy 
of the ventricular portion of the organ ; which last, as has been remarked by 
various writers, is probably owing to the diseased state of the nutrient vessels 
and the imperfect supply of blood. The case occurred in the practice 
of Dr. Webber, of Cambridgeport, and the patient was an old lady, 70 years 
of age, very fleshy, and had been subject, for five or six years, to paroxysms 
of great distress about the region of the heart, with numbness down the left 
upper extremity, lividity, and feeble pulse, obliging her to give up all active 
exercise. 

The large intestine was loaded with fat, and, as frequently happens when 
this is the case, the mucous membrane formed numerous little herniary sac- 
culi, many of them extremely thin, and some containing masses of indurated 
feces, as calculi are sometimes found in a sacculated urinary bladder. 

At the next meeting, Dr. Jackson reported a hospital case that he had since 
examined, and in which the coronary arteries were ossified, but without any 
cardiac affection, so far as was known during life; though, after the patient's 
death, his wife reported, on inquiry, some symptoms that may have been 
referable to the heart. 

Intussusception fatal, without complete Strangulation. — Dr. Snow exhibited 
the parts, and read a full history of the case sent by Dr. Cotting, of 
Roxbury, in whose practice it occurred. The patient was a healthy male 
infant, six months old. On Thursday, P. M., the 8th inst., it had two 
small, loose dejections, with traces of blood; about midnight, a large, loose, 
mucous, and bloody dejection ; and towards morning another, without 
pain. On Friday morning, Dr. Cotting found it slightly unwell, with rest- 
lessness, nausea, and occasional distress, which was referable to the bowels. 
Hyd. c. creta was given; and, for the night, Dover's powder. On Saturday 
morning, the distress had greatly increased, but without any marked heat, 



1852.] Morland, Extracts from Soc. for Med. Improvement. 



79 



tenderness, or fulness of the abdomen; slight retching; no dejection; rest- 
lessness and thirst greater, and pulse very rapid. Half an ounce of castor oil 
was given and retained. At 2 P. M., it was found moribund, gasping, and 
gagging. Had had a pretty large fecal and bloody dejection between 10 
and 11 o'clock, after which the abdomen began to swell, and became greatly 
enlarged. Intussusception was diagnosticated, and several attempts were made 
to force water up into the bowels, but without effect. Just before death, which 
occurred at 6 P. M., it threw off a little thin liquid, but it could hardly be 
called vomiting; and this was the only time that anything was thrown from 
the stomach during the attack. Neither was there ever any proper tenes- 
mus ; though throughout the last day there was very frequent and sudden 
action of the abdominal muscles, a sort of incomplete, abruptly-terminating 
strain. 

On dissection, the ileum was found to have passed through the coecum and 
into the ascending colon; the whole lying about over the right kidney, and 
red from increased vascularity, but soft, and so far from being strangulated 
as to be withdrawn by very slight traction. Appendix coeci scarcely involved. 
Upon the inner portion of the intestine, Peyer's glands were as much developed 
as in typhoid fever, being quite soft, with some red points and some lymph 
upon the surface, which was very irregular ; the mucous membrane itself being 
not remarkable. Upon the middle portion the mucous membrane was mo- 
derately red and rugous for about half its extent from the free extremity, but 
without much mucus, and with no blood or lymph. The passage through 
the intussusception, before it was withdrawn, seemed sufficiently free; the 
intestine above Toeing rilled with liquid, and that below comparatively empty. 

Disease of Knee-joint, of twenty years' duration — No treatment during 
that period — Amputation.- — Dr. H. J. Bigelow showed the specimen, 
lately removed by him from a young man who had gone about with it nearly 
all his life, suffering, comparatively, but little pain. The cartilage had 
undergone the so-called " pulpy degeneration," and, in several points, the 
bone was denuded. Dr. B. remarked that, previously to amputation, he had 
spoken of the oocasional deceptiveness of the fluctuating feel, as indicative of 
the presence of fluid; but he had not supposed it deceptive in this case. On 
examination, however, no fluid was found; but & deposit of fat, infiltrated with 
serum, existed between the patella and the tibia, two and a half inches thick, 
and by this was the fluctuating sensation caused. The patient is now well, 
with good union of the stump. 

Dr. Bigelow also reported the two following cases, and exhibited the speci- 
mens : — 

First. Peculiar fusiform tumour occupying the whole left thigh. The pa- 
tient was a female; the swelling, twenty -four inches in circumference at its 
largest part, gave to the touch a sense of ascitic fluctuation; its surface smooth; 
originally small, it had existed for seven months, with but slight pain. 

Exploration by acupuncture furnished two teaspoonfuls of watery blood ; a 
few days afterwards, a small incision made in the lower portion of the swelling 
allowed the finger to reach a mass of a placental feel, and a jet of blood, and 
then coagula, followed its withdrawal. 

There had been little doubt as to the existence of encephaloid disease, but 
no indications of this were detected by microscopic examination. After the 
above operation, the patient, previously much reduced, suffered an increase of 
an inch in the tumour within twenty-four hours, and died during the subse- 
quent week. The post-mortem appearances were: 1st. A sac filled with 



so 



Morland, Extracts from Soc. for Med. Improvement. [July, 



blood and coagula, the before-mentioned fusiform swelling. 2dly. The femur, 
stripped nearly bare of muscles, was abraded in one or two spots near the 
trochanter minor, and a small hole was discovered, piercing its shaft, the me- 
dullary cavity highly inflamed throughout, and traces of inflammation running 
into the cancellated structure of the femoral extremities. No free pus dis- 
covered. 

Dr. Jackson remarked the apparent encephaloid nature which one portion 
of the discharged material exhibited. 

Dr. Bigelow replied that this had been carefully examined by him under 
the microscope, and that it was concrete pus. 

Dr. Inches mentioned a case, somewhat analogous, arising from over-exer- 
tion of the limb; the swelling fusiform; pus was finally discharged. The 
patient is now thought to have necrosis. 

Secondly. Dr. Bigelow presented a specimen of Osteoid Cancer of the 
Femur, taken from a man of 22 years, who, while going up stairs, " felt 
something give way," and soon after noticed a tumour in the ham, which grew 
rapidly, but was without pulsation. Leeches applied by the patient were 
ineffectual. Dr. B. saw him in the country, and, pronouncing the disease 
malignant, advised amputation. Previous exploratory incision detected can- 
cerous tissue. The operation was done. This tumour, like the former, was 
fusiform; no disease of the knee-joint. 

On sawing the bone, Dr. B. found what he had never previously seen in 
the recent state — true osteoid cancer; a mass of friable, porous, fine structure, 
corresponding in appearance to pumice-stone; its consistence chalky. 

This disease has been known to return upon the system as bone, in various 
organs, as the lungs, veins, &c. Dr. B. pointed out a nodule of encephaloid 
matter in sound medullary tissue, half way up the shaft of the femur, which 
showed the mode of return and propagation of the disease in the continuity 
of a bone. 

Incisor Teeth from the Lower Jaw of a neicly-Lorn Child. — Dr. Gould 
presented these, which were loose in the jaw, and, causing irritation to the 
child's gums and to the mother's nipples, were removed. 

Dr. G. said that Dewees mentions having seen but one case of the kind. 
It is stated that children born thus are short-lived. The teeth, in this 
instance, are of the size usually observed in children of 18 months. 

Decidua in an Unimpregnated Uterus. — The case occurred in the prac- 
tice of Dr. Greene, who was called to the patient when she was in a state 
of stupor, having taken, it was said, about an ounce of the oil of tansy, 
and from the effects of which she soon died. She was about 25 years of 
age, a woman of dissolute habits, and, according to her sister's report, con- 
sidered herself pregnant, as there had been vomiting, with suppression of 
the catamenia, for the last three months. Besides the large dose of poison, 
there was reason to suppose that she had been taking smaller doses occasionally 
during the last month. 

The dissection was made by Dr. Ainsworth, and the parts were exhibited 
to the Society by Dr. Jackson. The uterus is not enlarged, but there is the 
vascular and softened, or rather flaccid condition that belongs to the gravid 
state. The body and fundus are lined by a decidua, which Dr. J. remarked 
upon as perfectly resembling that which he has found in at least three cases 
of early pregnancy. This structure is evidently a change to some depth of 
the inner surface of the organ, and not a newly-formed membrane; being two 



1852.] Morland, Extracts from Soc. for Med. Improvement 



81 



lines or more in thickness in the body, and becoming quite thin at the fundus 
and towards the cervix, at the upper limit of which last it terminates. It has 
a pulpy look and feel; an appearance, upon the cut surface, of very delicate 
and perpendicular strise; and upon the free surface the punctated appearance 
that characterizes the true decidua, and that is seen so frequently upon the 
fragments of this structure that come away with the ova, in the case of early 
abortions. A single incision has been made through the organ by Dr. A., but 
nothing like an ovum has been discovered. 

The left ovary is large, flaccid, and contains a spurious corpus luteum 
about the size of the top of the forefinger; i. e. a mass that consists mainly 
of coagulated blood, and is surrounded by a buff-coloured disk. The blood 
is not quite recent, judging from the consistence and colour, which last is not 
quite uniform. The colour of the disk resembles that of the true corpus 
luteum; but it is less lobulated, and varies in thickness, at different parts, 
from an almost inappreciable thickness to not more than half a line ; there is, 
moreover, no appearance of a lining membrane within it. A well-marked 
serous cyst is also seen, of an oval form, and equal to one-third of an inch in 
diameter; this contained an old, brown coagulum, but there is no trace of a 
buff- coloured disk about it. The other ovary is in a perfectly normal and 
passive state; and in neither of the two organs is there anything like a true 
corpus luteum. The left Fallopian tube is completely obliterated by old adhe- 
sion just at its fimbriated extremity, so that impregnation of the corresponding 
ovary could not possibly have taken place; the mucous surface being of a deep 
red colour, and smeared over with a whitish puriform fluid. The other Fallo- 
pian tube is quite normal. 

Encephaloid Disease of the Peritoneum. Hsematoid Variety. — Case 
reported by Dr. Perry. The patient was a large, fleshy, and healthy 
woman, 63 years of age; had been ailing for about one or one and a half 
years, but without any marked symptoms. Attended to her domestic affairs 
until three months ago, when the abdomen was found to be enlarged, and she 
was thought to be dropsical. Three weeks before death she was taken with 
dyspnoea and distress in the chest, and sent for Dr. Perry. The abdomen was 
enlarged as in the latter months of pregnancy, and fluctuated very distinctly; 
the lower extremities were (edematous; the complexion had a pale, sallow hue, 
and cancerous disease in the abdomen was diagnosticated. The dyspnoea re- 
curred in frequent paroxysms, and in one of them she died; no especial cause 
being found for this symptom. 

The dissection was made and reported by Dr. Jackson. The peritoneal 
cavity was filled with tumours, growing as it were from the membrane, and 
without involving the subjacent parts; varying, generally, from the size of a 
pea to nearly that of the fist; more or less pedunculated, and of a well-marked 
encephaloid character. The largest were more or less mixed with liquid blood ; 
this and the pulpy encephaloid were, in some of them, in about equal propor- 
tions; and in two or three cases nothing whatever was found but a cyst filled 
with blood. The most prominent object, however, was a large cyst in the 
middle of the abdominal cavity, probably not less than a foot in diameter, 
and containing by measurement eleven pints of dark-coloured and perfectly 
liquid blood. The parietes of this cyst, which had generally but a slight con- 
nection with the surrounding parts, were dense and averaged nearly a line in 
thickness, with some thin layers of encephaloid upon the outer, and some 
upon the inner surface. There was also upon the inner surface a coarse, 
friable, granular deposit, varying from two to four lines in thickness; many 



82 Morland, Extracts from Soc. for Med. Improvement. [July, 



parts, however, were nearly or quite free from it : this was probably coagu- 
lated blood, and with this exception, and a small coagulum in one of the other 
tumours, there was not a trace of coagulum to be found in any one of the 
masses. Encephaloid disease was also found in the liver, but in no other 
organ of the abdomen or thorax. There was no ascites, which so generally 
accompanies this form of carcinoma. 

Dr. Bacon, having taken some of the liquid blood for examination, found 
granular exudation-corpuscles and irregular masses of granular matter, in 
addition to the usual corpuscles, but no coagula of fibrin, the blood-disks 
retaining their normal shape. The blood is feebly acid, but no signs of coagu- 
lation are obtained by neutralizing it with ammonia. Amount of albumen 
sufficient. 

January 26. — Material conta ined, in a Tumour upon the Thigh of a Boy 
— its Character, &c. — Dr. H. J. Bigelow showed some of the contents of a 
swelling upon a boy's thigh, which came on after carrying a heavy burden 
that rested continuously for some time upon the spot where the tumour sub- 
sequently appeared. The affection was of three weeks' duration. The ma- 
terial exhibited was almost exactly the same in appearance and characteristics 
as that shown by Dr. B., at the last meeting, from the thigh of a female patient. 
The masses, looking like encephaloid matter, were undoubtedly pus mingled 
with coagulated blood; there was no malignant disease; the bone, at the seat 
of the swelling, was denuded; the popliteal artery laid bare. When the 
tumour was first opened, fluid blood first issued, then coagula. 

Dr. Bigelow also presented to the Society's notice a fibroblastic tumour 
which grew from the anterior walls of the abdomen, and resembled in shape 
a long Carolina potato. Situated near the inguinal ring, it was not connected 
with it; it was hard and knobbed. Extirpation advised and done. Through- 
out its whole extent, the mass was very closely adherent, and held in a net- 
work of tissue similar to its own, the cells of both being exactly alike. This 
latter fact explains the occasional reproduction of such growths, after extirpa- 
tion. The nutrient vessel was on the side of the skin. Two beautifully 
executed drawings of the tumour, in situ, and after removal, and also some 
microscopic delineations of the cellular structure, were shown by Dr. B., with 
the specimen. 

Dr. Bigelow likewise described the following case, intending to show the 
specimen at the next meeting: — 

Necrosis of the Maxillary Bones; of the Nasal Plates; and of the Sella 
Turcica, resulting from the Fumes of Phosphorus. — In March last, a man 
with an immensely swollen lower jaw, and highly inflamed tongue and 
gums, presented himself to Dr. Bigelow for advice; diagnosis difficult. 
Leeches were ordered. Dr. Bigelow left town soon after for Europe, and 
in a fortnight after, Dr. Gay saw the patient. The parts affected had now 
opened, and a probe detected dead bone. The man entered the Massachusetts 
Greneral Hospital, his health continuing to fail; remaining awhile, he left, to 
re-enter, some time afterwards, and was found there by Dr. B. on his return. 

In December last, drowsiness supervened, and, finally, a comatose condi- 
tion, lasting for three days, when death occurred in January. Post-mortem 
examination discovered the lower and upper maxillae extensively necrosed, 
the nasal cavity invaded by the same disease, and also the sella turcica. The 
meninges inflamed; the arachnoid opaque near the sella turcica. The patient 
had been engaged in the fabrication of friction matches, and thus exposed to 
the fumes of phosphorus, which at last caused the disease. 



1852.] Morland, Extracts from Soc. for Med. Improvement 



83 



Dr. Bigelow said this was the first case of the sort he had known to 
occur here. It has been reported in Europe. 

Degeneration of a Fibrous Tumour of the Uterus, with Encysted Dis- 
ease of the Ovary. — Case reported by Dr. Stedman. The patient was a 
married woman, 45 years of age, and died of some pulmonary affection, 
having had no symptoms of uterine disease. She was confined, for the last 
time, six years ago, and then had twins. Menstruation regular, nearly till 
the time of death; occasionally very scanty; and when this was the case, she 
usually had haemoptysis. 

The tumour is about one inch and three-fourths in diameter, quite defined, 
surrounded by a cretaceous shell, and has throughout a dead, yellowish-white, 
opaque appearance, with some brownish discoloration. It is rather dryish 
than otherwise, and quite as dense as any fibrous tumour, though the fibrous 
structure is less marked than it usually is. 

No trace of the left ovary is seen ; but in the place of it is a thin and simple 
serous cyst, nearly two and a half inches in diameter. Upon the other side is 
a collection of cysts, forming a mass nearly twice the size of an English wal- 
nut, upon the surface of which the thin, flattened, dense, atrophied remains of 
the ovary are spread out. 

Dr. Jackson remarked upon this change of structure in the fibrous tumour 
as the result of an arrest of growth, and probably of atrophy; he has met with 
the appearance three or four times, but has never seen it described. The con- 
dition of the ovaries he thought remarkable, in connection with the persistence 
of menstruation. 

Anomalies of the Arteries; Brachial, Thyroid, and Renal; all from the 
same subject. — Dr. Kneeland showed these specimens, consisting of high 
division of the radial artery on each side — on the right, from the brachial, 
on the left, from the axillary artery; the brachial artery dividing at the 
elbow into ulnar and interosseous ; the middle thyroid artery, given off 
from the arteria innominata, running up the median line of the trachea; this 
is important, as in the operation of tracheotomy it might be wounded. The 
kidney of right side had two renal arteries; the left kidney normal. The 
specimens were all from a boy about five years of age. 

Syphilitic Disease of the Eye. Cases reported by Dr. Bethxjne. — Case 
I. — Mrs. D., 40. Health good till one and a half years ago, when an erup- 
tion appeared on the skin, considered by her medical attendant to be syphilitic, 
both from its appearance and from other circumstances, though an exact his- 
tory of her primary symptoms could not be obtained. 

One year ago, she was attacked with inflammation in both eyes. She re- 
covered from this with the exception of a weakness of the eyes, which still 
existed in a degree when, four weeks ago, the left eye was attacked with pain, 
redness, &c. Of late the pain has abated. She has taken mercury for this 
attack, so that the gums have been much affected, and still continue sore. 
Mow, on examination, remains of copper-coloured eruption on arms and body; 
right eye well, except the slight weakness above-mentioned; left eye cloudy, 
pink injection around cornea, surface of cornea quite dry, and lining mem- 
brane appears somewhat darker than right; pupil of moderate size, does not 
respond to the influence of light, but is nearly regular, and appears free from 
lymph. The sight is so much affected that she cannot distinguish objects. 

Treatment. — Vesication in the vicinity of the eye, the external application of 



84 



Morland, Extracts from Soc. for Med. Improvement. [July, 



stramonium, tepid lotions, and the internal use of hydriodate of potash, which 
was gradually increased to 30 grs. a day. Under this, the moisture returned 
in great part to the surface of the cornea, the cloudiness of the lining mem- 
brane nearly disappeared, the vascularity of the eye much abated, aud the 
pain left her, but the sight did not improve. The pupil was now distinctly 
seen to be perfectly clear, but it remained immovable. On the 31st, the 
hydriodate was omitted, and her general health being improved, she impru- 
dently exposed herself to cold, and the inflammation returned in the eye, 
though much less violently than at first This having partially subsided, she 
wished to return to the country, and Dr. B. recommended her physician to 
try the effect of Fowler's solution, not going beyond grs. v, three times a day, 
after the present inflammation should have left the eye. 

On the 27th of January, her attendant informed Dr. B. by letter that her 
sight had so much improved that she could distinguish objects at a distance of 
six or eight feet. There was still some opacity of the internal surface of the 
cornea — and she had had a fresh eruption on the left hand, mostly of the 
character of syphilitic acne. Dr. B. advised that the solution which had been 
suspended a few days should be again given, and the dose gradually in- 
creased to grs. x. 

Case II. — Mrs. S., about 30, was attacked with primary symptoms nine 
months ago. Eruption first appeared three months after. Now, December 30, 
has severe syphilitic ecthyma on lower limbs. Three months ago, left eye 
was attacked with inflammation, which one month ago resulted in total loss of 
sight. Has had much severe pain in and around eye, from which she still 
suffers, also from periosteal pains in the tibise. The globe appears generally 
but unequally swollen; chemosis; a small purulent deposit is seen under the 
conjunctiva, near outer edge of cornea; the cornea hazy; the pupil apparently 
closed by lymph, and the iris pushed forward nearly in apposition with the 
cornea. Between these textures are several small purulent collections similar 
to that under the conjunctiva. The sclerotic projecting at points shows the 
choroid through. The upper lid is swollen, and droops. 

Treatment. — Under the care of the gentleman with whom Dr. B. saw her, 
she had been taking the mandrake (podophyllum) for a short time, with 
apparent benefit. It was agreed that it should be continued, and Dr. B. also 
urged the free use of the hydriodate of potash ; likewise the occasional applica- 
tion of two or three leeches near the eye, and the vapour of anodynes. Under 
this, as her physician stated, two or three weeks after, she had improved some- 
what in her general health, and the pain in the eye had diminished. At the 
upper part of the ball the swelling had increased; as it seemed not improbable 
that this depended on a purulent collection between the deeper-seated textures, 
Dr. B. advised an incision at this point if the enlargement continued. 

Dr. B. added that in syphilitic disease of the eye, as is well known, the iris 
is the part usually most affected. This membrane was involved in both these 
cases, but not more than, if so much as, some of the others. On this account 
he thought these cases worthy of mention. 

February 9. — Oases of Fever; Diagnosis difficult. — Dr. Shattuck, Jr., 
reported the following cases, which he considered of interest on account of the 
difficulty of diagnosis. He asked, Must the first be considered a case of typhus, 
or ship fever, as it appeared when first seen, and as one might be led to conclude 
from the results at the autopsy? The patient was a stout muscular Irishman, 
thirty-two years of age, a resident of this country for three years. He had 
worked on a farm in W atertown. He had not been with sick persons, but 



1852.] Morland, Extracts from Soc. for Med. Improvement 



85 



attributed his illness to a habit of washing his person very freely in cold spring 
water when heated. In the latter part of September, he had a bad cough, pains 
in his limbs, dizziness, and on the 13 th October, he gave up work, having lost 
strength, and went to board with a family in Watertowtf; who came to this 
country at the same time with himself. He had a bad cough — expectoration 
free, offensive ; dizziness; he was in his bed a part of the day, but sat down to 
meals with the family, and ate some hearty food every day, and walked out 
every day. He complained also of pain in the chest, and consulted Dr. Whitte- 
more, to whom he seemed labouring under a bronchial affection. A moderate 
drinker, he took some spirit every day; submitted to no medical treatment; his 
cough gradually diminished, his strength returned, when, early in January, 
he exposed himself at night to cold and wet when under alcoholic and other 
stimulus. His symptoms returned ; a petechial eruption over his body was 
noticed by his host a few weeks before this relapse, when a woman and a child 
of the family had an attack of mild fever, and were sick for two or three weeks. 
Dr. Whittemore regarded their disease as continued fever, but spoke of it as pe- 
techial fever, not being in the habit of using the terms typhoid and typhus as 
distinctive of varieties of continued fever. The man did not improve, though 
he continued to walk out, to sit at table with the family, lying down at inter- 
vals in the course of the day. Dr. Whittemore saw him a second time, and at 
his request wrote a letter to the admitting physician of the Massachusetts 
G-eneral Hospital. In this letter he says: "As respects the nature of his com- 
plaint, I can only say, he has had cough for three months or more, and it has 
most probably arisen from neglected bronchitis. The cough, while I am writing, 
has occasioned expectoration of frothy mucus with a provocation to vomit, with 
exhaustion of the strength and with some hemorrhage from the nose." The 
patient rode to Boston, and entered the hospital on Monday, Feb. 2. On 
Tuesday morning, at the time of the visit, he was sitting by his bed, dressed, 
his intellect quick, his memory impaired, mind disposed to wander; he gave for 
the most part satisfactory answers to the questions; the eyes neither injected 
nor suffused; the hearing good; prostration; rather a dusky hue of the skin, 
and an abundant petechial eruption over the trunk and limbs; the pulse 120; 
the skin dry; cough; respiration hurried ; resonance diminished over both lower 
backs; less over right, where the respiration was feeble and rude. Over front 
chest resonance sufficient; expiration prolonged under both clavicles; no pain 
in side; expectoration of viscid mucus, with one or two rusty sputa; abdomen 
rather full, not tender on pressure; gurgling in right iliac fossa; several dejec- 
tions, the patient having taken, for two days, cathartic pills. The tongue dry, 
no sordes on the teeth ; thirst. He was put on gruel, and took pills of opium 
and carbonate of ammonia. He was restless and delirious at night, getting out 
of bed and going to the water closet, and two of the attending physicians of the 
hospital considered the aspect of the case so decidedly that of ship fever, that 
he was put in a small ward where no patients would be exposed to him. He 
then had beef tea and brandy punch at regular intervals. Subcrepitant 
rale was heard over the right lower back; in other respects the physical signs 
continued the same; the prostration became greater, and he died in the even- 
ing of the 5th. The autopsy was made forty hours after death. There had 
been but little emaciation; the cellular tissue under the skin of the abdomen 
loaded with fat, the petechial eruption still distinct; slight and old adhesions 
of both lungs; both of them congested, of a very dark colour; no hepatization, 
the anterior parts and edges being the only crepitating portions. The mucous 
membrane of the trachea and of the primary bronchi was of a dark, livid 
colour, some aerated serum and mucus, the contents of the bronchia ; the 



86 



Morland, Extracts from Soc. for Med. Improvement. [July, 



spleen large, of a dark colour, the two substances of the kidneys quite distinct. 
The mucous membrane of the stomach and intestines not remarkable. Peyer's 
patches not diseased. The liver weighed four pounds. 

Diagnosis is often difficult where we do not have a patient under observation 
during the whole course of the disease. If this man had continued fever, it is 
remarkable that he never should have been confined to his bed, and that he 
should have been disposed and able to eat solid food during the whole course 
of his illness, a period of nearly five months. If he had typhus fever, it must 
have been an idiopathic case. He and his friends asserted positively that he 
was never exposed to sick persons. The man with whom he boarded spoke 
of his expectoration, when he came to his house in October, as very offensive. 
Had he gangrene of the lungs at that time? 

The second patient was a muscular Irishman, 28 years of age, who landed 
in New York on the 1st of March, after a voyage of six weeks. There was 
no fever during the voyage, but two of the passengers had fever after landing. 
He was perfectly well for a week, and then was taken with chills, headache, 
loss of appetite, nausea — and remained in the house, but was not confined to 
his bed. On the 8th day, he walked to the hospital, and was seen for the 
first time on the 17th of March. Some headache, prostration, mind slow, not 
capable of prolonged effort. He had bled from the nose twice; disturbed, rest- 
less sleep ; pulse 90, skin hot and dry, tongue dry, abdominal fulness and 
tenderness; gurgling in right iliac fossa; three loose dejections from ^ss of 
castor oil. Numerous rose spots over trunk and thighs, some on arms. He 
took ten grains of Dover's powder every four hours during the first twenty- 
four hours, and the same dose every three hours during the second twenty- 
four hours. He had one or two loose dejections; there was somnolence — 
the skin moist. The rose spots became of a darker color, and faded less on 
pressure. The prostration increased. He was put on brandy and beef tea at 
regular intervals on the 22d, and died on the 25th, the 18th day of the dis- 
ease. The friends forbade an autopsy. 

Ought not this case to be regarded as one of typhoid fever? The eruption 
and the abdominal symptoms are characteristic of that disease, and yet, per- 
haps, all would not consider this diagnosis as correct. The opiate treatment 
seemed to be without effect. Would the larger doses, as administered by Dr. 
Henry, of Springfield, Illinois, have been of efficacy to arrest or modify the 
fever ? 

Fibrous Tumour of the Uterus. — The specimen was shown by Dr. 
Jackson, to illustrate the change of structure that may, after a long while, 
take place in these cases. The patient was 84 years of age, and had had 
swelling of the abdomen for more than thirty years. The tumour had no 
appearance of fibrous structure to the naked eye — though it was evident enough 
microscopically — but rather that of a uniformly and brilliantly white, glist- 
ening, and very flaccid, though tough cellular tissue ; the cut surface being irre- 
gular rather than smooth, as it usually is. The mass, as received from the 
country, was of a semi-spherical form, six inches in diameter, three inches in 
thickness, and invested over its whole convexity with a thick, cretaceous 
shell. 

Dr. J. also showed a recent uterus, in the cervix of which was a fibrous 
tumour about one and a-half inches in diameter; and remarked upon the 
extreme rarity of these tumours in this situation, so far as he had observed. 
The patient died of acute pneumonia, and the situation of this disease was also 
peculiar ; the middle and the greater part of the right lower lobes being hepa- 
tized, whilst the back and especially the lower back part were healthy. 



1852.] 



Morland, Extracts from Soc. for Med. Improvement. 



87 



Ovum retained fourteen months. — Dr. Jackson exhibited the specimen 
which he had received from Dr. Edwin Leigh, of Townsend, with the fol- 
lowing account of the case : The patient, was 42 years of age, and had borne 
six children; general health delicate for many years; and for the last three 
years, since a miscarriage, she suffered from prolapsus uteri. 

In the winter of 1850-51, she became pregnant, as she supposed. The 
catamenia ceased on the 8th of December, and have never regularly returned 
since that time. In February, there was morning sickness. Swelling and 
hardness of the breasts, but no pain; the swelling beginning to disappear in 
May. No quickening. Some fulness in hypogastric region, but this did not 
increase after the fourth month, and about the sixth month it diminished. 
During the first six months there were more or less hard and bearing-down 
pains. 

In June, 1851, there was some uterine hemorrhage for a few hours, and 
during the following week a little very dark discharge; after which there was 
another hemorrhage with a similar discharge, which continued for the next 
twelve days. In September, October, and November, there was, on three or 
four different occasions, a slight discharge, lasting for a week or more at each 
time ; very dark, sometimes quite thick, and often appearing like a dark, dirty, 
semi-fluid unguent. Discharge never purulent. Some pains, referred chiefly 
to the sacrum, during these months, but less than in the winter and spring. 
Uterus somewhat enlarged, and with greater irritability and tenderness than 
was usual during the few preceding years ; os tincse rather enlarged. The 
case, it was thought, might be one of false conception, and so the result 
proved. 

About the 18th of December, she had very considerable hemorrhage, with 
some pain, and followed by leucorrhoea; attributed to hard work. Ten days 
afterwards, a similar attack. About the 18th of January, 1852, severe pains 
came on and increased, with considerable hemorrhage, until the 22d, when the 
ovum was discharged. 

The mass was of a regular oval form, four inches in length, and two and 
a half inches in diameter. Externally it had the usual appearance of a re- 
tained ovum ; and, a section having been made by Dr. L., it was seen to con- 
sist of a whitish, opaque, ill-defined tissue, with some remains of the chorion, 
fibrin from blood that had formerly been effused, and numerous little cysts. 
There were also numerous cavities, from one to three or four lines in diameter, 
of an irregular form, and having a serous-looking surface within, though they 
did not appear to be cysts; in some of these were small, granular, cretaceous 
bodies, not unlike minute phlebolites. 

Case of Laryngitis reported oy Dr. Alley, occurring in the Charity Hos- 
pital, N. 0., under the care of Dr. Wederstrandt. — An Irish emigrant 
entered the hospital, labouring under severe symptoms of laryngitis ; reports 
that he has been suffering, for two weeks, with the complaint which now 
threatens to prove fatal. 

The treatment was general bleeding, tartar emetic, and the remedies usually 
resorted to in such cases. 

The disease was thought to be cedema of the glottis, and confined to the 
larynx. In spite of the best directed efforts, the patient gradually grew worse, 
his breathing became more difficult, the air entered his lungs by a long wheez- 
ing inspiration ; he sat upright in bed, pointed to his throat, laid his finger 
upon it, and prayed earnestly for relief by signs and in a feeble whispering voice. 
There were intervals of ease, after which the paroxysms of dyspnoea would 



88 



Morland, Extracts from Soc. for Med. Improvement. [July, 



return with much greater intensity, and threaten him with immediate suffo- 
cation. 

One morning, between one and two o'clock, Dr. W. was summoned to his 
bedside, with the notice that, if he did not go quickly and operate, he would 
find the man dead. He took his case of instruments and tracheotomy tube, 
and hastened to the ward. Scarcely had he entered the ward before the nurse 
exclaimed, " Dr. W., the man is dead I" On reaching his bed, the man 
appeared like one who had breathed his last; he lay still and pale, his lips 
blue, yet there was a perceptible pulse, and the action of the heart, though 
feeble, was not arrested. The loss of a moment would have been fatal. 

An incision was made into the trachea just below the cricoid cartilage, and 
enlarged with a probe-pointed bistoury. The lungs were inflated by breath- 
ing into the artificial opening, and the chest compressed with the hands so as 
to imitate the natural mode of breathing. 

In a little while the patient began to breathe, and looked around like one 
awaking out of a deep sleep. He was told how to clear his throat of the 
mucus and blood, which constantly collected in it, by closing the wound after 
a deep inspiration, and then either by coughing or making a strong expiration 
whilst the artificial opening was closed by the finger. When the bleeding had 
ceased, the tracheotomy tube, figured in the plates of Liston and Ferguson, 
was introduced, but worked so ill that it was found necessary to dilate the 
wound with a pair of dressing-forceps, the handles of which were kept apart 
by a wooden stretcher, and the instrument held by a piece of tape fastened 
around the neck. 

An hour after this, bleeding returned, and the patient was nearly suffocated. 
He was then raised by the heels, struck smartly on the back several times, 
and a clot of blood was disengaged from the throat, moulded into the 
form of the trachea. From that time the patient did very well. In a few 
days he was able to bear the tube, and could walk about the house and in the 
yard. Nevertheless, it was found that he could not dispense with the tube 
after the acute inflammation had subsided, and no oedema of the glottis or 
epiglottis could be felt with the finger. 

It was thought that there might be some ulceration of the larynx. The 
tube was removed, and after the practice of Dr. Horace Green, of New York, 
the nitrate of silver was applied. He was also subjected to a mercurial course, 
but all in vain. It was found that any foreign substance introduced upwards 
into the larynx gave rise to a violent cough and spasm of that organ, whilst 
the introduction of the same downwards and into the trachea produced no such 
result. 

The man remained several weeks in the hospital, and then took his discharge. 
One thing worthy of note is, that the tubes, though of silver, were rapidly 
corroded by the secretions of the larynx and trachea, and required often to be 
renewed. Several months elapsed after the patient left the hospital before 
he was heard from again. He called, one day, in fine health and spirits, and 
said that he worked daily on the levee. A year had passed away since the 
insertion of the tube. 

Six months after he called at the hospital, he died under very peculiar cir- 
cumstances. He had worn the tube until the soldering had softened between 
the body and rim of the tube. In an unlucky moment the body of the tube 
fell into the trachea beyond the reach of his fingers. His ignorance of anatomy 
induced him to push it still farther down with a quill, hoping, as his friends 
say, that he could push it into his stomach. No effort was made at the time 
to extricate the tube, and the man died after much suffering. On examination 



1852.] Morland, Extracts from Soc. for Med. Improvement. 



80 



after death, the body of the tube was found occupying the right bronchus — the 
lungs were both in a state of sanguine congestion as in the first stage of pneu- 
monia; the right side of the heart was distended with blood, the left compara- 
tively empty. The glottis and larynx were extremely narrowed as if by a 
stricture, and could not be dilated without laceration; the result, probably, of 
bygone inflammation. 

Dr. W. reports also a case of oedema of the glottis in a patient upon whom 
he operated for tracheotomy. The patient speedily recovered after wearing 
the tube one week. The same operation has also been performed successfully 
by Dr. Warren Stone, and by Dr. Barnes, of New Orleans. 

February 23. — Lupus. — Dr. Durkee exhibited a case of this disease. 
The patient was a female forty-five years of age. In July, 1849, a hard pimple 
appeared upon the right cheek near the inferior border of the malar bone. 
When first noticed, it was about as large as the head of a pin. In a few 
weeks, several others appeared in the immediate neighborhood of the first. 
Now, the tubercles are mostly in juxtaposition, and occupy about two-thirds 
of the integument covering the cheek bone, and extend a few lines towards 
the upper lip and nose. They are of a dingy-red colour. Some of the tuber- 
cles are now half the size of a common pea; others, of more recent origin, are 
smaller. Patient has enjoyed good health, except that for a short time past 
she has been troubled with indigestion, and the tongue is now deeply coated, 
and the bowels constipated. 

Dr. D. remarked that lupus presents three principal varieties : the first has 
respect to the extent of surface implicated; the second to the depth to which 
the morbid action penetrates the chorion ; the third, where the disease is ac- 
companied with hypertrophy, is what the older writers denominated the 
true noli me tangere. Sometimes all the varieties exist in the same subject. 
The causes of lupus are for the most part very obscure. 

The present case is exhibited, not because it is a remarkable one of its 
kind, but because the disease itself is rare in this country. 

Although two and a half years have elapsed since the first tubercle was 
developed, yet the diseased surface is not now larger than half a crown ; and 
it still preserves its original type. The tubercles have undergone no change 
since their first appearance, except a very slow augmentation — and quite re- 
cently a delicate squamous covering has appeared upon the summit of some 
of them; the patient has been somewhat annoyed with itching in the affected 
skin. During the last six months, the diseased spot has increased in size 
more than it did during the first two years. There is a patch of the same 
disease on the dorsal aspect of one of the ring fingers. Here it has a close 
resemblance to psoriasis. The skin is much thickened. The portion of skin 
affected upon the finger is about the size of a ninepenny bit. 

Dr. D. proposed to treat the disease locally, as he could hardly suppose 
that any constitutional remedies would be of service. He remarked that 
he should endeavour to improve the general condition of the patient — but that 
he should trust to local remedies for the removal of the cutaneous trouble, 
and that he should commence with the application of the saturated compound 
tincture of iodine; the formula for this preparation of iodine is not in the 
dispensatories. It is made by dissolving as much as possible of iodine and 
iodide of potass in spirit. When applied freely twice a- day, it will soon pro- 
duce a slough. 

Dr. D. stated that he had recently treated a case of lupus of twelve or 
fifteen years' duration, successfully, with topical remedies only. The case was 



90 



Morland, Extracts from Soc. for Med. Improvement. [July, 



a more interesting one than that now presented to the Society. The disease had 
extended over a surface three times as large as in the present case, and there 
had been a very trifling ulceration for some years. The cicatrix left after 
the curative process is complete is quite peculiar. The surface has a deli- 
cate blue tinge ; the integument is extremely thin, and slightly rugous. 

Rare forms of Cyst. — Dr. Henry J. Bigelow exhibited and described 
a specimen of the oleaginous cyst. This is the only one he has ever seen. 
On puncture, a bluish-white, milky fluid exuded. The sac is membranous, 
the fluid is oleaginous. Dr. B. spoke of the different forms of cyst: the 
gaseous cyst developed in the human subject — the parallel of Hunter's case 
of cyst in the omentum of the pig; the serous cyst. Six weeks ago, Dr. B. 
saw a child who presented a swelling on the left side of the neck of three 
weeks' standing, and which he regarded as the earliest stage of hydrocele of 
the neck; on incision, three to four ounces of limpid serum were evacuated. 
Dr. B. showed two drawings of the latter cyst, in situ; the integuments were 
healthy ; the child three months old. A drawing of the oleaginous cyst was 
also shown. 

Resection of the Head of the Femur. Dr. Henry J. Bigelow. — The sub- 
ject of this operation was a boy between nine and ten years old, some time 
at the hospital, with disease of the hip-joint. The operation was done on 
Saturday last. Dr. B. intended exsection of the head of the femur; on 
the application of the chain-saw, a portion of the bone came immediately 
away, at the first traction of the instrument. This piece is seen to be carious, 
and as if infiltrated with tubercular deposit. Much pus issued from the 
wound; the bone denuded and carious. 

When first seen by Dr. B., three months since, there was a swelling over 
the coxo-femoral articulation of the size of a cocoa-nut, and complete disloca- 
tion of the femur upon the dorsum ilii. Dr. B. reports the patient quite 
comfortable after the operation; cold water applications to the parts are grate- 
ful. The operation, in itself, he thinks will not prove more detrimental than 
the spontaneous opening of this large abscess ; he had undertaken it because 
it is stated that, resection being practised, the disease of the socket gets well; 
he did not know why this should be. 

[At the next meeting, March 8, Dr. Bigelow showed the bones composing 
the hip-joint of the above patient, who died twelve days after the operation, 
having been as comfortable as previously, and the pulse having been unaltered 
for three days. Death did not occur from the operation, per se, but from the 
effects of admitted air into the abscess, which, sooner or later, must at any 
rate have happened, decomposition of the purulent contents ensuing.] 

In connection with the above case, Dr. J. B. S. Jackson mentioned an 
instance of fibrous reparative formation, after resection — a strong and efficient 
limb resulting; the case being similar to that reported by Dr. Bigelow. 

Apoplexy. — Dr. Jackson reported a case of extensive effusion of blood 
into the pons Varolii. The patient was a man forty years of age, and of 
rather a slender figure. About 10 A. M. on the 17th inst., and whilst in 
his counting-room, he complained of a darting pain through one eye ; his 
countenance changed, and he was thought to be faint, but in about fifteen 
minutes he had a convulsion, and from that time remained insensible until 
his death, which occurred between one and two o'clock in the following 
night. Was visited by a homoeopathic practitioner, who reported that the con- 



1852.] Morland, Extracts from Soc. for Med. Improvement. 91 



vulsions continued until 3 P. M., and ceased after the use of a shower-bath, 
and the application of wet sheets; pulse 100; pupils about natural. The 
effusion extended into the crura cerebri and somewhat into the pia mater, but 
not into the ventricles. 

At a subsequent meeting, Dr. Homans reported a case of very extensive 
effusion into the cerebellum and ventricles, complicated with renal calculi.— 
The patient was a large, fleshy man, fifty-eight years of age, and intemperate 
in his habits both in regard to eating and drinking. The attack came on at 
5| P.M. with very severe headache, and it was with great difficulty that he 
was got home; soon became quite insensible, and continued so for five hours, 
when he died. There was stertor, and apparently perfect paralysis, but no 
convulsion; pulse full and strong; pupils of the eyes greatly contracted and 
perfectly immovable. The dissection was made by Dr. Jackson, who reported 
an effusion into the cerebellum and fourth ventricle of ^iiss, by estimate, of 
coagulated blood; the third ventricle being also distended, and the lateral 
ventricles containing coagula and bloody serum. Brain quite healthy, except 
for some of the yellowish gelatiniform softening of the remains of the cere- 
bellum, with some ecchymoses (capillary apoplexy} so often observed about 
the seat of an effusion, but not found in the case previously reported. Some 
disease of the arteries at the base, in both cases. 

The left kidney, from the above case, which was shown, was formed of a 
congeries of large cysts. Two of these contained calculi (oxalate of lime, &c), 
which adhered firmly to the soft parts; one of them being for the most part 
covered over with a white fibrinous substance which may have resulted from 
some former effusion of blood. In the pelvis there was also a larger calculus, 
of an elongated form, sending branches into the openings from some of the 
infundibula, and adhering to them so as entirely to prevent the escape of the 
fluid from the corresponding cysts. The other organs were sufficiently well. 
Disease of the kidneys had not been suspected; but after the patient's death, 
his wife reported that he had long been subject to pain in the loins, with some 
tendency to incontinence of urine. 

Profuse Salivation in a Female of eighteen years, four and one-half months 
advanced in pregnancy. The case was related by Dr. Co ALE. — The patient, 
married one year since, is well in health, notwithstanding the profuse salivary 
discharge, by which three or four handkerchiefs are saturated in an hour and 
a half. The flow of saliva is constant, and excessively annoying; notwith- 
standing, she gains flesh, and the system does not, apparently, suffer. The 
papillae of the tongue are very prominent, with some engorgement of the 
lining membrane of the mouth. No remedies Dr. C. has tried have been of 
the least avail. 

Dr. Storer observed that this was undoubtedly a sj^mptom of pregnancy ; 
that it is mentioned as such by most writers upon midwifery; he thought the 
cases must be rare, however: he had never seen but one case in his own prac- 
tice; in that case, the woman, in all her pregnancies, five in number, suffered 
exceedingly for two or three months, the inconvenience commencing early in 
each pregnancy. 

Dr. Jackson alluded to a similar case, which he reported fully at a subse- 
quent meeting. — The patient is a delicate woman, and has had seven children, 
besides two miscarriages. Salivation comes on with each pregnancy between 
the fourth and fifth week; and continues from four and a half months, which 
was the shortest, to the third day after confinement, which has been the 
longest period. Fluid seems to come from the mouth, and amounts in quan- 



92 



Morland, Extracts from Soc. for Med. Improvement. [July, 



tity to about three pints daily during the whole time; being fully established 
in two or three days from the time it commences, and going off at last even 
more suddenly. Attended throughout with nausea, and often with vomiting; 
distress after food, and constipation ; to which symptoms she is not subject. 
Is salivated equally when sea-sick, but not when affected with common nau- 
sea. Dr. J. has recently attended her in confinement, and tried a great va- 
riety of remedies to check the salivation ; but it continued unabated during 
the greater part of her pregnancy. 

[Dr. Blundell (Diseases of Pregnancy: Prin. and Pr act. Midwifery, p. 
1129) remarks that " very copious salivation will sometimes occur during 
gestation, and where the patient has not taken one grain of mercury." He 
adds that he saw a case of this sort strongly resembling mercurial ptyalism; 
the fetor and ulceration of the gums, however, were wanting. " If the quan- 
tity of saliva is not very great, the patient may swallow it ; and thus some- 
what moderate the exhaustion which would otherwise occur." Dr. Blundell's 
patient secreted saliva so plentifully, however, that, when she swallowed it, 
the stomach was offended and vomiting ensued. If salivation be very pro- 
fuse, and the system suffer much, he recommends the induction of delivery; 
which, in all probability, would cure the disease; but where the secretion is 
smaller, a remedy of this kind would not be justifiable. " Meddlesome mid- 
wifery is bad." Dr. B.'s patient, above referred to, did well without inter- 
ference; from his reporting only one case, the rarity of the affection may be 
inferred.] 

Dr. Coale read to the Society the subjoined letter from Mr. Robert 
Ceeley, of Aylesbury, England, and prefaced the reading with the following 
remarks : — 

" From the circumstance of several cases of smallpox and varioloid occur- 
ring in persons who had been previously vaccinated, I was induced last autumn 
to suspect the efficiency of the vaccine matter in current use amongst us. I 
therefore wrote to Dr. G-olding Bird, one of the Physicians of Guy's Hospital, 
London, asking him to procure me a crust direct from a cow affected with the 
original vaccine disease. Though a perfect stranger to me, and I without the 
slightest claim upon him, he at once interested hiujself in the affair, and wrote 
to his friend, Mr. Ceeley, of Aylesbury, who had given much attention to the 
subject of vaccination, and had published some valuable papers upon it. This 
last gentleman procured what I desired, through a similar kind interest and 
zeal of Mr. Badcock, of Brighton, and transmitted the cow matter to Dr. 
Bird, with the following letter, which I will read to the Society. 

" The matter thus procured I have exerted myself to distribute as widely 
as possible, considering the kind exertions of the gentlemen in furnishing it, 
not so much a favour to me personally, as the promptings of a generous 
humanity to benefit all. I believe the physicians of the city are now gene- 
rally supplied with it. 

" I feel it due to the zeal and care of two of our own physicians to state 
that, upon the first publication of Mr. Ceeley's experiments, Dr. Adams, of 
Waltham, and Dr. Putnam, of Boston, immediately repeated them, and suc- 
cessfully, furnishing the city and neighbourhood with all the vaccine matter 
used here since that period; a fact, however, of which I was ignorant when I 
sent to England for a new supply." 



1852.] Morlandj Extracts from Soc. for Med. Improvement 



93 



Aylesbury, December, 1851. 
My Dear Sir: Your application on behalf of Dr. Coale, of Boston, U. S. of 
America, would have been most cheerfully complied with had it been in my 
power to do so. 

Similar applications for crusts and charges of primary vaccine lymph, have 
been often made to me from various parts of Great Britain and the continent, 
since the publication, in 1839, &c, of my "Observations on the Variolas Vac- 
cinas, as they appear in the Yale of Aylesbury, with an account of some 
recent Experiments on the Vaccination, Betro-vaccination, and Variolation of 
Cows." (Trans, of the Provincial Medical and Surgical Association, vol. viii. and 
x.) But, I regret to say, that of late years the cows here have failed to yield 
me the supply of lymph and the opportunities for observation they formerly 
did. 

The vale of Aylesbury is now, to all appearance, barren of primary vaccine, 
and void of materials for observations which I would gladly prosecute, and 
which ten or twelve years ago occupied so much of my time. 

The milkers in general, nowadays, have all undergone vaccination, and being 
thus less susceptible to the severe influence of the natural vaccine disease, are 
not apt to apply for surgical aid. We may, therefore, for this reason, lose 
occasional opportunities of detecting the disease in the cow; but there can be 
no doubt that the true variola vaccina is now a rare disease in this locality, 
while the other contagious eruptive diseases of the animal (nearly always con- 
founded by the milkers and dairymen with it), are as common as ever. 

You are aware that in my " Observations" just referred to, I entered fully 
into the subject of the vaccination, retro-vaccination, and variolation of the 
cow, and the effects of the resulting lymphs on man. 

In my successful experiments on the variolation of the cow, and the produc- 
tion of the vaccine lymph, in February, 1839, I furnished indisputable proof of 
a very interesting and important pathological fact. A fact which had long 

been doubtful and disputed, notwithstanding the previous experiments at , 

in 1801 ; by Gassner, in 1807 ; Sunderland and others, subsequently ; and, 
lastly, of Thiele, in South Russia. 

But to those who thought a new stock of vaccine lymph was occasionally 
desirable, or who might need a supply when no other source was at hand ; this 
pathological fact yielded additional reason for congratulation. 

Hence the lymph thus obtained by me, on two or three such occasions in 
that year, was much sought after, and was abundantly distributed by me over 
England, Scotland, Ireland, Europe, Africa, and North America (I think). 

It was kept also under my own observation for more than two years, was 
tested by smallpox virus and effiuviee, and found equal in all respects to the 
Jennerian lymph of 1800. 

In December, 1840, an intelligent chemist of Brighton, Mr. Badcock, think- 
ing with many others that a new stock of vaccine was needed, and being, as I 
understand and believe, unacquainted with my successful experiments, com- 
menced, for the above purpose, the variolation of the cow, and he was singularly 
successful. Having a high opinion of such lymph above that long in use, he 
has, for the last ten years, occupied himself in procuring it for his own use in 
vaccinating children, and distributing it to professional applicants. 

Being intimately acquainted with Mr. Badcock, whom I consider deserving 
of infinite credit for his zeal, perseverance, and great liberality, I have applied 
to him for a new supply for Dr. Coale. After about twenty fruitless attempts, 
he has at last succeeded in his endeavours, and I have now the pleasure of 
sending you, for Dr. C.'s use, a most liberal and choice supply. The parcel 
contains the following, viz. : — 

1. The crusts from a variolated cow. 

2. A glass charged from the same source. 

3. Some points charged from a splendid vesicle raised on a child's arm by 
some of the above primary lymph. 

All these are to be employed in the usual way; but I generally find the most 
successful method is to rub the lymph on small clusters of superficial scratches 
No. XLVIL— July, 1852. 7 



94 



Morland, Extracts from Soc. for Med. Improvement. [July, 



of the skin (instead of puncturing it). I hope this stock, of what I first de- 
nominated variola vaccina, will prove successful in use. 

In regard to the vexed question of the deterioration of the current vaccine 
by frequent human transmission, you are aware that I have fully discussed 
this subject in my "Observations," &c. 

That variolous lymph can be and has been deteriorated by a variety of causes, 
is indisputable. The fact is notorious in India [Quart. Journal of the Calcutta 
Medical and Physical Society, April 19, 1837). It has been proved in Paris 
(Notice sur le Cowpox decouverte a Passy, par M. Bousquet, 1836). It has 
been demonstrated in London (Report on Smallpox, by Dr. Gregory, Med. Gaz., 
Feb. 24, 1830). That it may be rendered weak and inefficient by accident or 
carelessness, by ignorance, or something worse, every experienced vaccinator 
will readily allow. 

But that the above results in temperate climates, and with every attention and 
care required, are inevitable, I do not think satisfactorily proved. But the fact 
of actual degeneration can alone be settled by a reference to the standard of 
Jenner. Of the correctness of this standard no one can doubt. I have repeat- 
edly proved it by the use, at different times, of natural and artificial vaccine, 
from at least fifteen or sixteen sources. If any given lymph possess the sen- 
sible properties described by Jenner in his first work ; if in the majority of 
subjects, it produces a vesicle of the normal size and form, yielding a readily 
infective lymph on the 8th day, after which period an areola commences and 
increases till the 10th or 11th, and the vesicle change into a hard dark crust on 
the 14th or 15th day ; I cannot see that it is possible to impeach the efficacy of 
that lymph. Its failure to protect from smallpox must depend on other causes. 
Uniform or very frequent deviations from the standard of 1800, to me would be 
conclusive of such a fact, and compel me to seek a new supply. Repeated ob- 
servations of the constitutional effects of all the vaccine I have ever used, 
enable me to corroborate the assertion of Jenner, that the primary disturbance 
is slight and trifling, the secondary, attending the local erysipelatous inflamma- 
tion, though often severe, are not essential to the specific influence, though 
they mark the completion of a process and afford satisfactory evidence of a 
previous important fact. As I have said elsewhere, " My own repeated appli- 
cations to the cow have been chiefly for the purpose of experimenting for the 
satisfaction of patients or for the accommodation of friends, not from any belief 
in the superior protective efficacy of such lymph over active current humanized 
lymph. 

" But when lymph is found uniformly deficient in infective property (Bous- 
quet, loc. cit.) — vesicles abnormally rapid in their course, at their greatest 
development on the 7th day ; yellowish in appearance on the 8th ; with turbid 
lymph, central desiccation, on the 9th ; and a miserably small crust, falling on 
the 15th or 18th day — such lymph, or anything approaching it, ought to be 
rejected." 

* * * * Mr. Badcock intends contributing to the great exhibition 
to be held in New York, in the form of Daguerreotype illustrations of the 
result of some of his experiments. * * * * * * * 

Yours, very truly, 

ROBERT CEELEY. 

To Dr. Golding Bird. 

Poisoning by Cyanide of Potassium. — Dr. Perry related the case. A 
nurse administered this poison, by mistake, to a child who had slight cough, 
instead of a cough mixture which stood near the bottle of solution of the 
cyanide. 

The immediate effects of the dose were vomiting and convulsions; then in- 
sensibility, locked-jaw, coldness of extremities, which were pendulous and with- 
out muscular power — diminished frequency of respiration (12 to 16 per minute), 
the pulse small, but distinct, 60 per minute ; the circulation languid, pupils di- 
lated, sphincters paralyzed; the teeth closed so firmly and continuously, that 
only once or twice could anything be poured into the mouth. 



1852.] Morland, Extracts from Soc. for Med. Improvement. 95 



Dr. P. saw the child in fifteen minutes after the accident, and found it in 
a warm bath, and insensible. Treatment. — Stimulants externally and inter- 
nally; mustard bath; inhalation of ammonia. Death was sudden. No post- 
mortem examination obtained. The quantity of the poison taken was not 
very far from gr. iv. ; the strength of the solution of the salt was 3j to 3j 
of water. Taylor states that gr. iv will prove fatal in ten minutes; this 
child lived one and a half hours. Dr. P. remarked that this is the first case of 
the kind he had heard of here. 

Puerperal Peritonitis. — The case was reported by Dr. Homans, and was 
interesting in connection with its presumed cause. The husband of the 
patient was suffering at the time from diffuse cellular inflammation about 
the elbow, with a discharge of pus for two days before her confinement; 
and to this, as a cause, Dr. H. was disposed to attribute her disease. For 
the first two days she did well; but on the third day there came on chills 
followed by heat, with tenderness of the abdomen, anxiety and restlessness, 
headache, vomiting, and diarrhoea. Six or eight dejections daily. On the 
fifth day she was somewhat better, but the abdomen was more tender. On 
the sixth day worse, with light delirium ; and on the eighth day after her con- 
finement she died. The abdomen became very tumid, and the diarrhoea con- 
tinued to the last. Some secretion of milk; but cessation of lochia. No au- 
topsy. 

March 8. — False Membrane of Croup. — Dr. Bowditch showed a very 
perfect and remarkable specimen of the membrane formed in the above dis- 
ease. It was a complete cast of the larynx, trachea, and primary divisions of 
the bronchi, and was thrown up, entire, after the use of calomel and ipecacu- 
anha. Nitrate of silver was subsequently used, by the advice of Dr. B., on 
the return of dyspnoea, which was relieved after the membrane came away, 
but became aggravated in the evening of the same day. The solution was of 
the strength of to 3jj of water. The sponge, about three-fourths of an 
inch in diameter, well filled with the solution, was applied to the epiglottis 
and its neighbourhood, thoroughly, once ; vomiting immediately followed, with 
copious discharge of mucus; the breathing was again relieved. The solution 
was applied through the night, every two hours, by Dr. Hoi man, of Harvard, 
Mass., with whom Dr. Bowditch saw the child, and who communicated the 
after particulars of the case to Dr. B. The child was at first skilfully and 
judiciously treated by Dr. Newell. In addition to the application of the 
caustic, the powders were continued with emetic effect. On the 8th of March, 
(the child having been first seen by Dr. B. on the 6th, with Dr. Holman) 
after giving a powder, the solution was applied, vomiting followed, and an- 
other portion of membrane was thrown off about one-half the size of that ex- 
hibited to the Society. This was, apparently, mainly from the bronchi of the 
right side. Dr. Holman writes to Dr. B. that this latter discharge of mem- 
brane entirely relieved the croupy breathing, and the cough lost its distinctive 
character. A blistering tissue (4 — 4 inches) had been applied, previously, 
below the right clavicle, where signs of bronchial inflammation had been ob- 
served; the bowels were moved by oil. Thirst subsided; appetite began to 
reappear. R. Decoct. Senegee; small doses, every three to four hours. 9th 
March. Best good the previous night; respiration for past twenty -four hours al- 
most perfectly natural; voice does not return; light food apparently relished. 
10th. Report favourable; child calls for food; pulse 80; breathing natu- 
ral; cough infrequent; stomach and bowels quiet; disposed to sleep. 11th. 



96 



Morland, Extracts from Soc. for Med. Improvement. [July, 



Morning; slept all night, except when aroused; but quite restless, flinging 
the arms about and frequently moving from one side of the bed to the other 
without waking. Pupils, on examination, enlarged; eyes not injected. Som- 
nolent tendency, which finally became stupor, and death occurred at 11 
o'clock P. M. No post-mortem account is given. [The attack was on 
March 1 ; duration of disease, consequently, ten days, some hours. The child, 
a female, three years and a few weeks old ; previously in excellent health.] 

Dry Clironic Arthritis. — Dr. Henry J. Bigelow brought a series of 
joints, affected, in different degrees, by the above disease. The specimens 
were taken from a dissecting-room subject. They were like those showed 
at a former meeting, but presented, from one subject, almost all the va- 
rieties of appearance resulting from this disease, from a simple depression in 
the cartilage, to great wax-like deposit upon che articular edges (gouttelettes dc 
cire), partial dislocation, and foreign bodies. 

Fracture of the Radius. — Dr. H. J. Bigelow exhibited some specimens of 
rather rare fracture of the radius. This bone, Dr. B. remarked, is nearly al- 
ways transversely broken. The first specimens shown were from a man who 
fell from a mast-head, producing compound fracture of the femur, with dis- 
placement and fracture of both wrists. Death, the next day. One radius is 
seen to be split through its articular surface, obliquely to its dorsal aspect, like 
Barton's fracture; all the dorsal aspect of the joint being broken off. In the 
other radius there was oblique stellated fracture of radius on the surface of 
the joint; no great deformity of the joint. Dr. B. pointed out a piece of bone 
in one of the ligaments of the joint. 

Strangulation from Enlarged Tonsils — Laryngotomy. — Dr. J. M. War- 
ren showed the larynx of a man on whom he had performed the ope- 
ration. The patient was brought into the hospital struggling for breath, and 
almost pulseless, supposed to be labouring under an attack of laryngitis. 
The danger of suffocation was so imminent that no time could be spared to 
inquire into the history of the case. Dr. W. had the patient placed immedi- 
ately on his back, and proceeded to open the larynx — a matter of some diffi- 
culty — owing to the violent efforts of the patient for breath. As soon as the 
air penetrated freely into the larynx, he began to revive; the pulse became 
more steady; the respiration regular. Stimulants were exhibited both by the 
mouth and per anum, but the system had received too severe a shock to recover, 
and he gradually sank and expired quietly in an hour or two after the opera- 
tion. On removing the larynx, no marks of inflammation of that organ could 
be detected. On looking further, however, the cause of death was discovered. 
The tonsils, greatly enlarged, and in a state of violent inflammation, filled up 
the posterior fauces. The epiglottis had been gradually encroached upon, so 
that, finally, it was pressed down, and almost completely prevented the en- 
trance of air into the lungs. The history of the case, as learned afterwards 
from the father of the boy was this : He had been employed, four days be- 
fore, in unloading a ship, the weather being very cold and rainy. The fol- 
lowing day he was taken with sore throat, for which some simple remedies had 
been applied on board the vessel where he slept. He was first seen by a phy- 
sician on the day he was brought to the Hospital. 

Gall-stones ; with Ulceration of the Duodenum, as if to give exit to 
them. Fatal Hemorrhage from the Ulcer. Case reported by Dr. HoMANS. 



1852.] Morland, Extracts from Soc. for Med. Improvement. 97 



— The patient was a large, fine-looking man, 49 years of age, but sub- 
ject to colic. Five weeks ago lie was taken with a pain across the upper 
half of the abdomen, having somewhat of a rheumatic character, and followed 
in a few days by jaundice; the skin and urine being tinged with bile from 
that time, and towards the last, deeply so. He kept his bed for a few days, but 
was soon out and able to attend to his business. Nine days ago he was at- 
tacked, whilst walking in the street, with a violent pain in the abdomen, nausea, 
and vomiting; and, from that time, was confined to his room and mostly 
to his bed. The nausea, however, of which there was none in the early part 
of his sickness, soon subsided ; but the pain continued until the last, being of 
a colicky, paroxysmal character, with tenderness on pressure over the seat of 
the disease. Appetite small from the time of the first attack ; and the bowels 
very costive, the dejections being clay-coloured, with much flatulence for the 
last two or three weeks. Five days ago, he had, after a laxative, the first 
discharge of blood, which was tarry in appearance, consistent, and rather large ; 
and twelve or fifteen hours afterwards a second, of liquid blood, and about half 
a pint in amount. The number of these discharges altogether was not more 
than three or four. On Friday night he had one which was estimated at three 
pints, became exceedingly faint, nearly pulseless; and, from that time, sank 
regularly until this morning at nine o'clock (Monday), when he died. 

The dissection was made by Dr. Jackson, and the parts exhibited by him 
to the Society. The ulcer, which was well defined and apparently recent, com- 
menced one-fourth of an inch from the pylorus, and measured one and a quarter 
inch by three-quarters of an inch. From the base there hung off a firm coagu- 
lum of the size of a nutmeg; the small intestine being dark-coloured throughout 
from the quantity of blood- it contained. About a dessert-spoonful of small, 
round, smooth calculi were contained in the gall-bladder and ducts ; the first 
being of medium size, though the parietes were diseased. The ducts, however, 
were considerably dilated; the cystic measuring transversely at its largest 
part, when cut open, one and a half inches, the hepatic, one and three-quarters 
of an inch, and the common duct two inches, but contracting gradually to its 
natural size where it opened into the intestine. The most interesting point, 
Dr. J. remarked, was an adhesion of the duct to the external surface of the 
intestine, and just at the situation of the ulcer, though there was no appearance 
of ulceration nor of any other disease of the duct itself; the ulceration com- 
mencing upon the inner surface of the healthy intestine, and apparently with 
a view to open a communication with the ducts, as, in the case of aneurism 
of the arch of the aorta, ulceration not unfrequently begins upon the mucous 
surface of the air-passages or oesophagus, and not upon the inside of the aneu- 
rismal sac, where perforation seems to be the ultimate object. The liver was 
olive-coloured, small, and quite flaccid, but apparently healthy in structure, as 
were the other organs. 

March 22. — Cancer of the Breast. Dr. J. M. Warren presented the 
specimen and related the case. — The patient was 50 years old, and the opera- 
tion was done at the hospital. A year ago, a small movable tumour existed 
in the right breast; eight months since, she applied to a "cancer doctor/' who 
may be said to have manured the lumps with caustic; for, under its constant 
application since, the disease had increased so as to present a formidable tumour 
surmounted by a circular ulceration. The tumour was quite unattached to the 
pectoral muscle, and the whole apparent disease removed by the knife. 

Two or three axillary glands, enlarged from the irritation kept up by the 
caustic, disappeared a few days after the operation. The patient was sufficiently 
recovered in a fortnight to go home. 



98 



Bigelow, Action of Cochituate Water on Leaden Pipes. 



Dr. W. had seen one or two cases lately of cancer of the breast treated by 
caustic, in which the result has been similar to the one above stated. 

Sympathetic Trouble in the Ears from Disease in the Eyes. — Dr. Be- 
thune related the case. — A single lady, between 50 and 60, who had com- 
plained of headache, had occasional diarrhoea, and was affected with pity- 
riasis — was subject to tinnitus aurium after using the eyes in reading, expo- 
sure to gas-light, &c. There was stiffness of the lids with lachrymation. 
General means, with counter-irritation, were successfully used. Dr. B. said 
that this is the first case of the kind he has observed. 



Art. VII. Report on the Action of Cochituate Water on Leaden Pipes, and 
the Influence of the same on Health. By Jacob Bigelow, M. D., Pro- 
fessor of Materia Medica and Clinical Medicine in Harvard University. 

The committee appointed by the Society of Medical Improvement in 
Boston, for investigating the question of the occurrence of any diseases attri- 
butable to the presence of lead in the aqueduct water introduced into the 
city, from the Cochituate Lake, in January last reported as follows : — 

That from an extensive inquiry among physicians, and also from the bills 
of mortality, they are led to believe that the health of the city of Boston has 
been uncommonly good during the last two years, and they have not learned 
that any well-marked cases of the diseases usually attributed to lead, have 
occurred, which were not traceable to some other cause than the use of 
Cochituate water drawn from leaden pipes. 

It appears from the experiments of Professor Horsford, that the water of 
the Schuylkill and Croton Rivers, and of Jamaica and Cochituate Lakes, acts 
upon the surface of the lead so as to take up a small portion of that metal 
during the first two or three days of its contact. But after a few days the 
surface of the lead becomes coated with an insoluble compound which pro- 
tects the lead for the most part from the further action of the water. Never- 
theless, traces of lead are reported to have been found by various chemists, 
in specimens of some of these waters, when greatly reduced by evaporation. 

Id consequence of the extensive use made of lead for various economical 
purposes, no person in civilized society can expect to escape from the recep- 
tion of that metal in minute quantities into the body. The presence of lead 
in the paint of dwelling-houses and furniture, of water-buckets and other 
culinary apparatus, in vessels made of leaden alloys or soldered with the 
same, in the lining of tea-chests, in flint-glass, and in the glaziDg of coarse 
pottery, furnishes but a part of the examples which indicate our exposure 
to receive this metal in our daily food. To these examples it may be added 
that physicians give lead to their patients sometimes for weeks successively, 



1852.] Bigelow, Action of Cochituate Water on Leaden Pipes. 99 

and apply solutions and solid compounds of the metal to absorbing surfaces 
for longer periods ; that persons are known to carry shot and bullets in their 
flesh during a long life j and, finally, that reliable chemists testify that lead 
exists in the solids and fluids of man, and in those of some of the animals on 
which he feeds. 

From all these facts we are authorized to draw the conclusion that, in the 
present state of our knowledge, the presence of lead in a very minute amount, 
like the presence of other substances in infinitessimal quantities, is inoperative 
upon the living body. 

It is a general law known to medical men, and to which there are not 
many exceptions, that diseases and symptoms produced by specific metallic 
agents, such as mercury, lead, and arsenic, do not cease until after the with- 
drawal of those agents. But it appears from the records of the Massachusetts 
General Hospital, during the last twenty years, as well as from the private 
experience of physicians, that many cases of lead colic and paralysis, acquired 
by persons who work in that metal, have got well under the daily use of 
water delivered from leaden pipes. This would not probably have been the 
case did the water contain any deleterious amount of lead in solution or sus- 
pension. 

The principal diseases ascribed by Tanquerel, and some subsequent writers, 
to the presence of lead, are colic, paralysis, arthralgia, and encephalopathy. 
Of these the committee have not been able to learn that there has been aay 
sensible increase in this city since the introduction of Cochituate water. Of 
lead colic, but one case has entered the hospital during the last two years, 
which is a smaller proportion than the average of the preceding twenty years. 
Of lead paralysis there have been but two cases within the same period, both 
occurring to workmen in lead. Of arthralgia or pain in the joints or limbs 
directly traceable to lead, it is believed there have not been a sufficient 
number of cases at any time to attract extensively the notice of our physicians. 
As to encephalopathy, a general term used by some writers to express cerebral 
disease, and including coma, delirium, convulsions, &c, there is apparently 
no more reason for attributing it to lead, than consumption, fever, or any 
other common disease which may happen to occur among lead workmen. 

It is obvious to a medical reader, that many of the cases detailed by 
writers on lead diseases are coincidences rather than consequences ; and, there- 
fore, do not furnish a ground for general laws. Such is the case when per- 
sons have been supposed to have contracted lead diseases by sleeping in 
newly-painted apartments, where, unless the lead were volatile, it could not 
leave the walls to enter the bodies of the patients. It is also the case when 
solitary examples of common diseases are ascribed to lead, when it is known 
that they more frequently result from different causes. It is also often the 
case when the reports of credulous and incompetent observers are received 
as scientific authority. 

In a late " English Beport by the Government Commissioners on the Che- 



100 Bigelow, Action of Cochituate Water on Leaden Pipes. [July, 

niical Quality of the Supply of Water to the Metropolis/' of London, made in 
1851, by Drs. Th. Graham, W. A. Miller, and A. W. Hoffman, men of high 
standing in the scientific world, an investigation is made of the condition of the 
various waters now supplied to that city. In this Report, the commissioners 
state (page 32) that "no recent or authenticated case can be cited of the health 
of any of the numerous towns lately supplied with soft water, being affected 
by the use of leaden distributing tubes." Again, on page 33, the commis- 
sioners say : " We are disposed, therefore, to conclude that the danger from 
lead in towns supplied with water, has been overrated ; and that, with a sup- 
ply from the Water Companies, not less frequent than daily, no danger is to 
be apprehended from the use of the present distributing apparatus, with any 
supply of moderately soft water which the metropolis is likely to obtain." 

On the present occasion it is by no means intended to deny the well-known 
fact that certain acid liquors, also that the water of certain springs and wells, 
may and do act upon and even dissolve lead in such quantities as to prove 
injurious to human health. It is also possible that at certain seasons, and 
under certain circumstances, the soft water of lakes and rivers may contain 
organic or other products, which may take up in solution a minute portion of 
the pipes through which they pass. And it may even be conceded as pos- 
sible, that a few susceptible and predisposed individuals will get lead diseases 
while using this water. Nevertheless, lead is a very convenient material to 
be* used in aqueducts. It is more cheaply manufactured, more conveniently 
applied, and more readily repaired, than any other material. And while this 
is the case, mankind will not be prevented from employing it. The general 
law derived from the experience of the large cities of this country and of 
Europe is, that its employment for the conveyance of soft water is safe. To 
this law the few recorded cases of disease, as far as they are genuine, must be 
regarded as exceptions. And it should be borne in mind that nearly all the 
great agents which minister to the physical happiness and improvement of 
man, are fraught with more or less danger. Ships and railroads, fire and 
water, food and medicine, destroy annually multitudes of our species. Never- 
theless, all these agents increase every year in use, with the increase of 
wealth and civilization. And as an humble example under the same law, it 
is not probable that the leaden aqueduct will be abandoned, on account of 
the inconsiderable risk which it involves of occasioning disease. From the 
present state of our knowledge, we are authorized to conclude that the in- 
surance on a citizen of Boston, New York, Philadelphia, or London, against 
lead colic, is probably worth much less than his insurance would be on a 
voyage across the Atlantic. 



1852.] Lattimore ; Chloride of Sodium in Intermittent Fever. 101 



Art. VIII. — On the Employment of the Chloride of Sodium in the Treatment 
of Intermittent Fever. By W. P. Lattimore, M. D. 

The discovery of some agent capable of serving as a substitute for Peru- 
vian bark, or for its active principle, quinia, in the treatment of intermittent 
fever, has long been desired, in consequence of the high price of the sulphate 
of quinine, and the great adulteration of the salt to which this has given 
rise. The amount paid for quinine alone, is no small item in the annual 
expenses of the country physician ; and this is likely to be increased, as it 
is said that a company of English druggists have monopolized the entire 
crop of Peruvian bark for many years to come. 

In view of the interest necessarily felt in this subject, we have thought it 
might not prove uninteresting to the readers of the American Journal, to give 
the results of investigations made by the eccentric Piorry, upon the use of 
common salt in the treatment of intermittent fever. The investigations were 
commenced at La Pitie, and continued at La Charite, where they were wit- 
nessed by the writer. 

The attention of M. Piorry was drawn to the subject by a memoir, pre- 
sented to the French Academy of Medicine, in July, 1850, by Dr. Scelle 
Montdezert, entitled, Practical Considerations upon the Treatment of Inter- 
mittent Fevers, and upon the mode of action of the Salts of Quinia, and of 
the Chloride of Sodium. 

In this memoir, M. Scelle Montdezert supposes that every paroxysmal fever 
is due to the presence of fibrin in the venous blood; this fluid, in the normal 
state, being deprived of fibrin by the process of assimilation. That the salts 
of quinia owe their efficacy as anti-periodics to the fact that they dissolve 
this fibrin abnormally present, thus restoring the venous blood to its nor- 
mal conditions. In casting about, then, for a substitute, he saw that 
nature had largely disseminated both potassa and soda, each possessing, in a 
remarkable degree, solvent properties. Seeking, among the various combina- 
tions of each, that one which, uniting with the divers elements of the blood, 
should furnish the fewest insoluble compounds, he naturally selected the 
chloride of sodium, which forms none. He administered it, and then goes on 
to say : — 

"On account of these considerations we experimented without fear of injury, 
and we declare with satisfaction that the results of its employment are such 
that salt may now be considered as sharing with the salts of quinia the prero- 
gative of arresting the paroxysms of intermittent fever. It is sufficient to ad- 
minister half an ounce of it in the morning, before eating, during the apy- 
rexia, in half a glass of infusion of coffee. Its use should be continued fur 
three days; 

" Fortunate results, observed during several years, have confirmed our fore- 
sight. It is a counter-proof of our opinion, long since emitted, upon the action 
of the sulphate of quinine, and one which gives the most satisfactory solution 
of this therapeutical problem." 



102 Lattimore, Chloride of Sodium in Intermittent Fever. [July, 

M. Scelle Montdezert gives the history of no cases treated by salt, al- 
though he alludes to many in which the agent was successfully employed. 
Under these circumstances the matter came into the hands of M. Piorry, who 
was one of the committee appointed by the Academy to report upon the 
memoir, and his cases are the only ones known to us. From these re- 
searches it will be seen that the chloride of sodium cures intermittent fever, 
like the sulphate of quinine, by acting upon the spleen and diminishing its 
volume, and this sometimes in less than a minute. And in this connection it 
may be of interest to say a few words in regard to the views of M. Piorry 
concerning the spleen in intermittent fever, and his method of diagnosticating 
the disease. 

He holds that in all paroxysmal fevers the spleen is enlarged \ that the ana- 
tomical lesion is the cause, the fever only the symptom ; that wherever the 
spleen has a greater length (measuring in a line extending from the middle 
of the axilla to the anterior superior spinous process of the ileum), than from 
31 to 33 lines, intermittent fever exists. Believing thus, the symptoms for 
him are zero, while the state of the spleen stands at the other end of the 
scale, and is everything — percussion (pleximetric) of course, being the ex- 
perimentwn cruris. 

We cannot resist the temptation of here paying a tribute to the skill 
with which M. Piorry employs percussion in making a diagnosis. With him 
auscultation is but an infant when compared with its full grown brother per- 
cussion. By its aid he interrogates the abdominal viscera as frequently as 
the thoracic, and with no less success, for he has brought it to an almost 
incredible degree of perfection. With his plate of ivory and his flattened 
fingers' ends he diagnosticates almost everything — tumours of the abdo- 
men, abscesses everywhere, aneurisms, &c. All acknowledge the delicacy and 
accuracy of his test, while the looker on is lost in admiration, and wonders 
whether all his senses are not really concentrated in the ends of his fingers, 
which by constant drumming have at length become the very reverse of 
tapering. 

Wishing, then, to experiment with salt, a few cases of intermittent fever 
(old stagers), contracted in Algiers were selected as subjects. Behold, then, 
Piorry at the bedside. The patient asserts that he contracted the fever 
and ague several years since in Africa; that he has frequently been cured; 
but that the disease has constantly reappeared at the end of fifteen days 
or one month at farthest. The type of the fever is tertian. The spleen 
is percussed and found to be abnormally dull throughout its whole extent; 
the entire splenic region is sensitive upon percussion, particularly over the 
dullest points; and each blow is accompanied by marked contortions of 
the countenance. This sensibility extends but little beyond the region of 
dulness, which last occupies an extent of fifty-three lines, measuring in the 
direction indicated above. To this patient a drachm of salicine is administered 
without producing any change in the dimensions of the spleen. A few min- 



1852.] Lattimore, Chloride of Sodium in .Intermittent Fever. 103 

utes subsequently, half an ounce of salt mixed with a cup of soup is given, 
and upon carefully percussing the splenic region at the end of four minutes, 
this organ is found diminished one inch, from above downwards. The next 
day the spleen is found to be of the same size, but upon the administration of 
a second dose of salt, it suddenly contracts and measures nearly three-quarters 
of an inch less than yesterday. The resonance throughout the entire organ 
has increased while the sensibility has diminished. The succeeding day, the 
attack of fever is very slight, and upon giving a third dose, the disease does 
not return ; and when seen six weeks subsequently, the patient is still free 
from his African enemy. Thus we see that a diminution of twenty-four lines 
in the length of the spleen was the result of the medicament, the fever being 
cured more effectually than ever before; i. e., the patient had remained free 
from all relapse for the space of six weeks ; one month having previously been 
the longest period of immunity. 

We have the notes of seven cases of well-marked intermittent fever, in all 
of which the administration of the chloride of sodium was followed by rapid 
decrease in the volume of the spleen and cure of the febrile symptoms. We 
also have the record of three cases in which salt was unsuccessfully used; in 
one of these, the sulphate of quinine effected a cure ; in a second it too failed, 
while in the third it was not tried. These were all well-marked cases of inter- 
mittent fever, such as would pass muster in any of our own malarious dis- 
tricts. 

Let it be remembered that most of the fever and ague met with in the 
Parisian hospitals, is of long standing, and imported from the malarious dis- 
tricts of Algiers, which generate a form of the disease even worse than that 
found amid the marshes on the banks of the famed Maumee; that these cases 
have been treated again and again, have been cured now by the sulphate of 
quinine, now by arsenic, but only to reappear upon the slightest exposure or 
imprudence; in short, to recur as only the shakes can recur. 

We witnessed many of the experiments of M. Piorry, and in the great ma- 
jority of them, the fever yielded to salt quite as readily as to the salts of 
quinia. And as to the theory of M. Piorry, the spleen diminished under the 
use of the remedy, pari passu, with the febrile symptoms, in every case 
where the disease was cured, proving that this organ really shows the influ- 
ence of remedies over this class of fevers — that it is, as it were, a febro- 
barometer — for the diminution of the spleen is a constant phenomenon accom- 
panying the cure of the disease, whatever be the curative agent employed. 

M. Piorry's method of administering the chloride of sodium is, to give half 
an ounce in a cup of thin soup during the apyrexia and fasting. It usually 
agrees with the stomach perfectly well, but in some few cases we have seen it 
excite vomiting and diarrhoea. Three doses commonly suffice to effect a cure, 
the first two to be taken on succeeding days, and the third after an interval of 
one day. Should the spleen be undiminished in volume by the first dose, we 
may be sure that the remedy will not cure the disease; and the same is true 



104 



Troy, Nature and Cause of Tubercular Deposits. 



of all the antiperiodics. Excepting in rare cases, the diminution of the spleen 
occurs immediately upon the administration of the remedy (salt or sulph. qui- 
nine), and may frequently be detected within one minute, after which the organ 
remains stationary until a second dose of the medicament be administered. 

Is the chloride of sodium as efficient an antiperiodic as the sulphate of 
quinine ? Are the cures effected by the one as permanent as those effected 
by the other ? The first question can only be answered by those possessing a 
larger field of observation than the writer. May we not hope for a solution 
from those of our profession who observe the disease too largely either for 
comfort or pleasure ? In regard to the permanency of the cures, we appre- 
hend there is not much difference, be the medication what it may; for re- 
lapses are only too common after the greatest care and most patient attention. 

Should the discovery prove as useful and applicable as it promises, the 
benefit accruing from it will be immense. If it be capable of taking the 
place of the sulphate of quinine in the majority, or even in one-half the cases 
of intermittent fever, therapeutics will be largely the gainer. 

New York, March 26, 1852. 



Art. IX. — New Views concerning the Nature and Cause of Tubercular 
Deposits. By Matthew Troy, M. D., of Whiteville, North Carolina. 

There is no disease, perhaps, in regard to the pathology of which a 
greater number of discordant theories have been advanced than that of tuber- 
cular consumption. This has arisen as well from its frequency and almost 
invariable fatality — which would naturally lead the profession to direct their 
most earnest attention to its investigation, in the hope of discovering for it 
some certain means of cure or prevention — as from the tangible nature of the 
product by which it is characterized, and which seems to invite investigation, 
by promising an easy and ready explanation of its nature and cause. In 
but few diseases can we lay hold of the materies morbi itself. But our being 
able to do so in the case of consumption seems to have been of but little ad- 
vantage in leading us to correct views in regard to its true nature and treat- 
ment. 

It is not my intention to attempt a history of the disease, or to discuss the 
comparative merits of the several theories that have been advanced in relation 
to it ; but shall merely, previously to offering my own views, give a brief 
notice of the present opinions of the profession as to the pathology of tuber- 
culous diseases generally. 

Three distinct theories are still held by respectable portions of the medical 
profession. Two of these are known as those of Andral and Carswell, the 



1852.] 



Troy, Nature and Came of Tubercular Deposits. 



105 



third, of which Dr. Charles J. B. Williams claims to be the author, I shall, 
for convenience sake, call by his name. 

The first two do not differ very materially from each other. Andral con- 
siders tubercle as — 

" Nothing else but a secretion of matter which seems to be produced 
indifferently, either in the last bronchi or in the vesicles which succeed them, 
or in the cellular tissue interposed between the latter, or in the inter-lobular 
cellular tissue. This matter, which seems to be primarily liquid, becomes 
solidified at a period more or less remote from that at which it was secreted, 
'and becomes a tubercle." — Med. Clinic, vol. ii. p. 212. 

" Dr. Carswell considers the tuberculous matter to be a secretion sui generis 
totally destitute of organization, as effete matter, continually separated from 
blood when this is in an unhealthy state, and thrown out chiefly on the free 
surface of mucous membranes ; and producing bad consequences only in 
proportion as it accumulates in organs, impedes their functions, and acts on 
them as foreign matter." — Williams and Clijmer on the Respiratory Organs, p. 
341. ' 

Neither of these views, even if true, would materially advance the state of 
our knowledge on the subject, as neither of them touch upon the cause of the 
secretion, or the nature of the diathesis in which it occurs ; nor does it ex- 
plain how this effete matter comes to be in the blood. This is the radical 
defect of Dr. Carswell's theory. My hope is to be able to remedy this defect. 
The theory of Dr. Williams is much more generally adopted than either of 
the others, notwithstanding the difficulties many have seen in it, because it is 
at least definite and tangible. 

"Instead of (with Laennec) classifying tubercle under the vague term of 
accidental productions, or (with Carswell) as a secretion sui generis, I have 
for many years referred tubercle to a degraded condition of the nutritive ma- 
terial from which old textures are renewed and new ones formed ; and that it 
differs from fibrin or coagulable lymph, not in kind, but in degree of vitality 
and capacity of organization." 

This theory I propose now to analyze, and see if the facts induced in its 
favour are sufficient to establish it beyond a reasonable doubt, and whether 
the arguments are all consonant with the well-known principles of physiology. 

The symptoms resulting from a deficiency of fibrin in the blood are well 
described by Dr. Williams : — 

" A defect of fibrin causes a tendency to hemorrhages, generally the asthenic 
kind, and to an unmanageable oozing of blood from any accidental wound or 
breach of texture. In the same cases, too, wounds do not readily heal nor 
fractures unite ; in fact, the plastic or reparative process is defective, for want 
of its material, and for similar reasons the nutrition of textures, which 
consist chiefly of fibrin, such as muscle, is ill-maintained." — Princ. of Med., p. 
108-9. 

We should suppose, where the material for the plastic or " reparative pro- 
cess" was " degraded," that the nutrition of the textures, which consist 
chiefly in the deposit of fibrin, would be ill-maintained for want of " capacity 
of organization" in its material. But the muscles do not suffer pre-eminently, 
or at least primarily, in phthisis. 



106 Troy, Nature and Cause of Tubercular Deposits. [J^y? 

What evidence have we that the fibrin in this disease is degraded ? Do 
not " wounds heal and fractures unite," sometimes with great readiness, and 
always as soon as in other diseases attended with an equal disturbance 
of the system ? Does the surface of wounds ever become coated with a 
deposit having the remotest resemblance to tubercular matter ? Is not 
the fibrin, which is effused upon them, capable of ready organization ? Why 
is not tubercular matter most frequently deposited in the substance of mus- 
cles, or wherever the nutrition is most rapid, the amount of interstitial 
change greatest, and the calls for efforts at organization most constant and 
considerable ? But this is not the case with the parts in which tubercle is 
most frequently effused. There is no evidence that the mucous membrane 
of the bronchial tubes is remarkable for the activity of its nutrition, and the 
same may be said of the lymphatic glands. In a word, the liability of 
any organ to tubercular deposits bears no relation to the quantity of fibrin 
ordinarily required for its nutrition. But is it not plain this would neces- 
sarily be the case if a diseased state of the fibrin had anything to do with it ? 
In fact, the fibrous tissues seem rather to possess a positive exemption from 
the disease : — 

" We have never found tuberculous matter in cartilage, fibrous tissue, serous, 
synovial, or mucous membranes, tendon, or muscle." — CarswelVs Cyc. of Pract. 
Med., art. Tubercle. 

Upon what principle of physiology can we conclude that, in a disease 
affecting in a peculiar manner the sole and entire organizable material of the 
blood, rendering it unfit for its office, the lungs would be the first part sen- 
sibly affected by abortive efforts at nutrition in so very large a proportion of 
cases ? Is it not perfectly plain, that when an entire principle of the blood 
is affected, the whole body must suffer, and the different parts of it in the 
precise ratio they make use of that principle ? This is the case in chlorosis ; 
and we must admit the possibility of an exception to the laws of nature, 
before we can allow that it can be otherwise in any disease. 

It is true that there is an excess of fibrin in the blood of phthisical patients, 
in the latter stages, but not until inflammation has been excited by the pre- 
sence of tubercles. If there were any foreign body — a bullet, for instance — 
lodged in the lungs, and not encysted, it would excite inflammation, attended 
by cough, purulent expectoration, &c. ; or, as Watson expresses it, " all the 
symptoms of chronic phthisis," and the fibrin would be found to be aug- 
mented in proportion to the extent of the inflammation. But it would not 
be very philosophical to ascribe the presence of the bullet to the excess of 
fibrin in the blood, even though we might not know positively how it came 
there. 

There is another reason, which of itself seems conclusive against tubercle 
being the plastic material in a degraded state. It is that plastic lymph is 
almost always thrown out in immediate connection with tubercular matter. 
In describing a vomica, Dr. Williams says : — 



1852.] 



Troy, Nature and Cause of Tubercular Deposits. 



107 



" The bloodvessels, however, are almost always impermeable in these cases, 
and the septa are thickened by the deposition of lymph, &c." — Williams and 
Clymer on Eesp. Organs, p. 329. 

Now is it not a fact of physiology, that where lymph is effused in contact 
with a structure formed of it, that it takes the form of that structure ? Is it 
not contrary to all that is known of pathological process, to suppose that a 
structure of lower vitality could have one of higher vitality formed in its 
midst, and from the very material by which this lower structure is produced ; 
more especially, while the causes of " degradation" are still in full force ? If 
tubercle is lymph, degraded of course, areolar tissue cannot be formed from 
lymph effused in contact with it; at least, until the causes of degradation are 
entirely removed. But if it is a foreign body, healthy lymph may be effused 
for the purpose of encysting it ; and this may be converted into a tissue by 
which the bloodvessels are closed and the septa thickened. 

The lymph corpuscles noticed by Mr. Gulliver in tubercular matter, do not 
go further towards proviDg Dr. Williams's theory, than any of the others. 
Whatever be the nature of tubercle, it is certainly capable of exciting inflam- 
mation in the tissues where it is deposited. This inflammation causes an 
effusion of plastic lymph, for the purpose of encysting the foreign body. But 
it being soft, liquid, Andral says (Sir Jas. Clark is of the same opinion, 
Cyc. Pract. Med., art. Tubercular Phthisis), and continually augmenting 
by fresh deposits, the fibrin is mixed with it, its corpuscles separated, and or- 
ganization prevented; producing precisely the appearance described by Mr. 
Gulliver. 

It now remains to state my own views of the nature of this deposit. It is 
with the greatest diffidence that I attempt what some of the greatest men 
who have ever adorned our profession have failed to accomplish, through a 
long life of patient toil and investigation, devoted to the subject. But they 
have cleared the way, and but little is left to do now but advance upon the 
smooth road they have made. 

I consider tubercle to be the solid matter of the cutaneous excretion, espe- 
cially of the sebaceous follicles. This secretion not being expelled by the 
natural emunctories, is retained in the blood until, in the attempt to elimi- 
nate it through an unnatural channel, it is deposited in some other excretory 
organ, where its fluid matter being absorbed, it becomes a tubercle. 

It will be first necessary to show that the secretion of the skin is of suffi- 
cient importance 'to produce this effect when retained. 

"It appears," says Dr. Carpenter, "that at least one hundred grains of effete 
azotized matter are daily thrown off from the skin .... When the exhalation 
of the skin is completely checked by the application of an impermeable varnish, 
the effect is not, as might be anticipated, an elevation of the temperature of 
the body ; on the contrary, it is lowered, in consequence, it would appear, of the 
interruption of the aeration of the blood through the skin, which is a function 
of such importance in the lower animals, and of no trifling account in man. 
And in a short time a fatal result ensues." — Elements of Physiology. 



108 Troy, Nature and Cause of Tubercular Deposits. [July? 

The amount of the cutaneous respiration has never been precisely deter- 
mined, but it will hardly be doubted that Dr. Carpenter has overrated its 
importance, when he considers that death takes place from its interruption. 
Even one whole lung may be rendered impervious, and still life may be pre- 
served j and the fact which settles the question entirely, is, that the body may 
be immersed in water containing but little air, or even in water from which all 
the air has been expelled by boiling, and no appreciable inconvenience results, 
notwithstanding the " aeration of the blood through the skin" is suspended. 
It is singular that such an every-day experiment should have escaped so acute 
an observer as Dr. Carpenter. 

It is plain, then, that death takes place in these cases, from the retention 
in the blood of the excrementitious matter ordinarily thrown off by the skin. 

Of the amount of the sebaceous secretion alone, we can only conjecture, as 
very little light can be thrown upon it by the ordinary experiments for 
determining the quantity of the cutaneous secretion. It is not volatile, like 
the perspiration ) it accumulates, and mixes itself with the epidermis j and 
the diminution of the weight of the body would no more show its amount, 
than it would that of the urinary secretion still retained in the bladder. 
But we are in possession of sufficient facts to show that it is very considerable. 
Any one who has been troubled with a dry, harsh state of the skin of the 
hands, and has attempted to relieve this by the rubbing on of any oily matter, 
must have been surprised at the quantity which may be made to penetrate 
the skin and disappear, before the natural state is restored. But the seba- 
ceous secretion keeps the skin of the whole body constantly in this state. 
Those, also, who have " dry" hair naturally, and keep it, by the application 
of oily matter, in the state natural to others, will be able to judge of the 
quantity requisite to effect this object. When we consider the vast number 
of the glandules of the surface by which the sebaceous matter is eliminated, 
we shall not doubt their capacity to furnish all that is required, either for the 
good or bad effects ascribed to it. 

The mucous membrane lining the bronchial apparatus and the alimentary 
canal, is but the inversion of the external tegument of the body, which it 
resembles in structure, and, to a great extent, in function; so nearly, that in 
the lowest animals there is no difference whatever between them, except the 
accident of position. This membrane is lined throughout its extent inwardly 
as well as outwardly, by numbers of minute glandulse; those on the external 
surface being estimated, by Mr. Erasmus Wilson, at not less than seven mil- 
lions in number. The action of all these glandulse is depuratory or excretory. 
The secretion of none of them is destined to be reabsorbed, nor can it be 
retained in the blood without injury to the system. 

No fact in physiology is better ascertained than that when the secretion of 
any organ, especially an excretory organ, is retained in the blood, an effort is 
made by some other organ, usually the one most nearly allied to it in func- 
tion, to eliminate it (Carpenter's Human Physiology, p. 608). 



1852.] Troy, Nature and Cause of Tubercular Deposits. 109 

Now, if the function of the skin is not properly performed, it is obvious 
that the mucous membranes will be the first to suffer ; that is, if they do not 
perfectly succeed in supplying, by a vicarious or augmented natural action, 
the depuration ordinarily effected by the suspended function of the skin. It 
is from the overwhelming congestion with which they are affected, in the 
attempt to eliminate the secretion of the skin, that death takes place when 
the secretion of that organ is completely suspended, as by a varnish, for 
instance. 

Is the function of the skin badly performed in phthisis ? Formerly a 
pearly white skin was considered characteristic of the disease, or rather of the 
tubercular diathesis. But it is now said that too much stress was laid upon 
this peculiarity, as the disease very frequently attacks those who do not pos- 
sess it. But when we look upon the skin as a gland, as a great depuratory 
organ, the retention of the secretion of which in the blood causes death in a 
few hours, it is hard to conceive that too much attention can be paid to its 
peculiarities in any disease. I believe all writers still recognize a peculiarity, 
a cognizable anatomical difference of structure from the healthy skin. It 
seems to be this, that the skin is harsh and dry. Let its texture be fine and 
white, or coarse and dark, it is uniformly dry and inelastic. It is easily 
washed clean ; dirt does not closely adhere to it. In a word, the sebaceous 
secretion is deficient. I cannot do better than give the description of this 
peculiarity in the words of Sir James Clark : — 

" The aspect of the countenance generally affords decisive indications of the 
presence of the affection ; in early childhood it has a pale, pasty appearance. 
If the complexion be dark, the colour of the skin is generally sallow ; if fair, it 
has an unnatural white appearance, resembling blanched wax rather than healthy 
integument. The cutaneous functions are rarely in a healthy state; the skin is 
either pale, soft, and flaccid, or dry and harsh, and frequently affected with 
eruptions. Its function of secretion is, in tuberculous subjects, always more or 
less deranged." — Cyc. of Pract. Heel., art. Consumption. 

If, upon examination after death from any disease, the liver, lining mem- 
brane of the alimentary canal, or kidneys were found in a state different from 
the healthy standard, this state would be considered as constituting a promi- 
nent feature in the pathology of the disease. 

Even if there was nothing in those who inherit the diathesis indicative of a 
deficient development of the glanduke of the skin, the causes which produce 
the disease are sufficient of themselves to point out its true nature. Every- 
thing which depresses the action of the skin tends to the production of tuber- 
cles. Everything which exalts its function acts as a preventive. 

"Decidedly the strongest of the predisposing causes," says Dr. "Wood, "is 
inheritance [congenital malformation of the secretory apparatus of the skin.] 
"Next perhaps in the degree of influence is cold. Allusion is not here made 
to the vicissitudes of weather which so frequently occasion attacks of inflam- 
mation. Cold may act in this way as an exciting cause ; but its most pernicious 
agency is probably connected with its long-continued application. * * * This 
fact has been strongly exemplified within my own observation." — Practice of 
Medicine, vol. ii. pp. 104-5. 

No. XLVIL— July, 1852. 8 



110 



Troy, Nature and Cause of Tubercular Deposits. 



Could anything be stronger evidence in favour of the idea that the retained 
secretion of the skin is the cause of tubercular deposits ? Is not this as nearly 
as possible reducing the condition of the subject to that of those who inherit 
the fatal peculiarity from their parents? All diseases attended by a great 
disturbance of the function of the skin are notoriously apt to be followed by 
phthisis. The exanthemata — smallpox, scarlatina, and more especially mea- 
sles — fevers in which there is much dryness or constriction of the skin — and 
diabetes, where this reaches the greatest extent, are extremely liable to be 
followed by consumption. 

The evidence deduced from the juvantia is not less strong. The influence 
of a warm, dry climate is too well known to require it to be dwelt upon. And 
its influence in developing the glandular of the skin, where they are deficient 
congenitally and in stimulating them where they are depressed or torpid, is 
equally well known. (See Carpenter' 's Elements of Physiology.} How can a 
warm climate affect the fibrin of the blood? The hygienic means next in 
importance; if not superior to the last, is vigorous exercise in the open air : — 

"Vigorous exercise and free exposure to the air are by far the most efficient 
remedies in pulmonary consumption. It is not, however, that kind of exercise 
usually prescribed for invalids — an occasional walk or ride in pleasant weather 
and strict confinement in the intervals — from which much good is to be ex- 
pected. Daily and long-continued riding on horseback or in carriages over 
rough roads is perhaps the best mode of exercise: but where this cannot be 
commanded, unremitting exertion of almost any kind in the open air amount- 
ing even to labour will be found highly beneficial." — Dr. Parrish — quoted by 
Wood, Practice of Medicine, vol. ii. p. 111. 

" They are most fortunate," says Dr. Wood, "who are so situated as to be 
compelled to exert themselves. It has often been observed that consumptive 
patients entering the military service have entirely surmounted the disease." 

"Dr. Guy found that in the close workshops of a printing establishment, 
the compositors whose employment requires no exertion fall victims to phthi- 
sis in the proportion of 44 to 31J per cent, of the pressmen, who, while breath- 
ing the same air, use active bodily exertion. Similar exercise in pure air would 
have much more salutary effects, the deaths from the same cause in out-door 
labourers not exceeding 25 per cent." — Williams's Princ. of Med., p. 53. 

Can the efficiency of active exercise in the open air be explained in any 
other way than by its powerfully stimulating effect upon the glandulae of the 
skin ? 

Other means having the same effect are equally lauded : — 

" No remedies of this class have appeared to be so generally useful as coun- 
ter-irritants of the milder class — rubefacients extensively and regularly applied 
by friction over a large surface of the body." — Williams's Princ. of Med., p. 310. 

Does not the difference in the complexion of men and women fully explain 
the greater liability of the latter to consumption ? It is interesting to notice 
the connection between the habits of the pig — his wallowiDg in the mire and 
choking up the pores of the skin, and his great liability to scrofula, to which 
he has given the name. 

Natives of a cold country going to a warm one suffer less from consumption 
than the natives of the latter; and natives of a warm climate going to a cold 



1852.] 



Troy, Nature and Cause of Tubercular Deposits. 



Ill 



one suffer far more. This is true of other animals as well as man. The ac- 
tion of the skin is exalted in the one above its natural standard, and depressed 
below it in the other. 

Is not the thinness of the aide, nasi, formerly considered one of the charac- 
teristic symptoms of the disease, owing entirely to the want of development 
of the sebaceous follicles usually so abundant in that situation ? 

But as to the nature of tubercle itself. Tubercle is evidently a foreign 
matter in the blood. Even if it is " degraded lymph," it is a foreign matter 
none the less ) for dead or dying fibrin has no place in the blood. Besides, 
all its habits, so to speak, so nearly resemble those of an effete matter retained 
in the blood, that it seems only to have been the difficulty of telling how it 
came there, that has prevented all from considering it such. It is perfectly 
evident that it has its origin in the system itself, for it is found under cir- 
cumstances (as in the foetus) where its introduction from without is scarcely 
possible. And whenever the diathesis is acquired, it is through the agency 
of depressing causes acting upon the general system. 

If there has been raised, by the facts I have just mentioned, a presump- 
tion in favour of the retained secretion of the skin being the cause of tubercu- 
lar deposits, this presumption will not be lessened by an examination of the 
deposits themselves, nor of the rules which seem to govern their distribution. 

The sebaceous secretion of the skin has not been analyzed with sufficient 
accuracy to determine its precise nature : " It is oil, but not oil alone f and 
as little is' known of the nature of the solid constituents of the other secretions 
of the skin. It is, therefore, impossible to demonstrate chemically their 
identity with tuberculous matter. But enough is known to show a very 
strong probability of this identity. 

Tubercle consists for the most part of minute granules, which either con- 
sist of, or are very easily converted into, fatty matter. 

" Every gradation may be found between euplastic and aplastic deposits; the 
cells and fibres which are the representatives of organization,* diminishing in 
number and completeness, and the material becoming more granular and amor- 
phous, or abounding in fat globules in proportion as the deposit is degraded, 
until in opaque, crude, or yellow tubercle it is altogether aplastic, consisting of 
a mere aggregation of granules and fat globules with mere traces of the remains 
of cells." — Williams's Princ. of Med., p. 300. 

Here at least we see one of the constituents of this secretion in the depo- 
sit ; and it is the only one that is known with certainty. It is very probable 
that this constituent of the sebaceous secretion can at any time be detected in 
the blood of phthisical patients : — 

" The fibrin of the blood presents under the microscope a predominance of 
granular matter and fat globules" — Id., p. 113. 

Is not this a stronger proof of the truth of my theory than the discovery of 
lymph-corpuscles in the substance of tubercle is of his ? 

* I have already shown how these come to be there. 



112 Troy, Nature and Cause of Tubercular Deposits. [Juty? 

The deposition of fat in the liver, causing what is termed " fatty liver/' so 
common in this disease, may also be regarded as proof that the great fat- 
secreting gland, the skin, is out of order. 

But the evidence afforded by the place and manner of the deposition of this 
tuberculous matter is stronger still. The sebaceous secretion not being tole- 
rated by the system, an effort is made to free the blood of it; and with Dr. 
Carswell, I believe this is always done through the mucous membranes, or in- 
ternal prolongation of the same membrane which should normally excrete it 
If the quantity to be got rid of in this way is small, or the cause obstructing 
the excretion of the skin be of short duration, no doubt this effort is often 
successful. There are perhaps but few persons who do not at times void through 
the mucous surfaces matters which are normally got rid of through the skin 
without feeling any inconvenience from it. But where the amount to be ex- 
creted in this way is considerable, there will always be more or less disturb- 
ance of the function of the lungs, kidneys, or alimentary canal. 

This may not be considerable, and will soon pass off if the skin resume its 
office. But if the cause of depression be permanent in its nature, or if, dur- 
ing its action, the secretory power of the mucous membrane be weakened or 
suspended by inflammation, or any other cause, a deposit takes place. 

The reason why the lungs are oftenest the seat of this deposit is very ob- 
vious. It may be that the closer analogy between the skin and lungs, than 
between the skin and any other organ, causes a greater quantity of the secre- 
tion to be directed to the bronchial membrane than to any other. But the 
anatomical structure of the lungs is fully sufficient to account for the fre- 
quency of the deposit in them. From all other mucous surfaces, any effused 
matter would find a ready outlet, by the force of gravity alone, or gravity 
aided by peristaltic action ; but here, gravity, which is the only force acting, 
unless cough be excited, causes the effused fluid to descend to the air-cells, 
where it accumulates ; its watery parts being absorbed almost as soon as it 
reaches the cells, we have a tubercle. Here it grows by attracting its 
like from the blood, as Dr. Williams has well shown. [Principles of Medi- 
cine.) 

This appears far more plausible than Dr. Williams's reasons for the fre- 
quency with which the lungs suffer: 1. " Their great vascularity and the large 
quantity of blood that passes through them, which makes them largely partake 
of any disorder in the condition of this fluid." If this were the case, they 
ought equally to suffer in chlorosis and scurvy, or even in rheumatism, for 
these and many more diseases depend upon a disordered condition of the 
blood as much as does phthisis. 2. " Their being a chief seat of the forma- 
tion of fibrin ; that principle being more abundant in arterial than in venous 
blood." Fibrin is more abundant in arterial than in venous blood, pro- 
bably because before it becomes venous it has to traverse some organ, 
which takes from it sufficient fibrin for its wants, but gives none to it in re- 
turn. Dr. Williams has very conclusively shown, in the same work, that 



1852.] Troy, Nature and Cause of Tubercular Deposits. 113 

fibrin is very rapidly formed in an inflamed part, without the agency of the 
lungs. 3. "The softness and yielding nature of their texture, which permits 
effusions to take place more readily than denser textures do." Other effusions 
seem to take place more readily in areolar tissue. 4. " Their exposure to ex- 
ternal causes of disease." The lungs are hardly more exposed to external 
causes of disease than the alimentary canal, and, laying aside tubercle, are 
hardly more often diseased. 

But the lungs are scarcely ever the seat of a deposit without other organs 
being affected also. The kidneys are almost invariably implicated ; not always, 
however, by a deposit, for, excepting in the cortical portion of the kidney, the 
matter has free egress merely by the laws of gravity ; but the structure of the 
gland is often spoiled by its being compelled to eliminate another secretion 
than its own. The connection of Bright's disease with the scrofulous consti- 
tution has been noticed almost as long as the disease itself. This disease we 
can produce at will, merely by partially obstructing the cutaneous secretion 
by varnish or otherwise; and I am more convinced of the identity of the 
granular matter in this "degeneration" of the kidney with the granular 
matter of tubercle, from the identity of the causes producing it, than from 
all the observations and experiments yet made in relation to it. I con- 
sider Bright's disease to be merely an abortive attempt, on the part of the 
kidneys, to eliminate the sebaceous secretion of the skin, which, instead of 
being voided, is deposited in their secreting structure; its peculiar appear- 
ance being due to that structure. This view receives confirmation from the 
great increase of oil-globules noticeable in the epithelium-cells of the kidney 
in this disease, which Dr. George Johnson considers the first pathological 
change which takes place in Bright's disease. 

The albuminuria is, I suppose, caused by the congestion this deposit gives 
rise to, in the same manner as it would be by congestion from any other 
cause. 

The gastro-intestinal mucous membrane was found healthy by Andral in 
only one-fifth of the cases examined by him. But it is not to be supposed 
that it did not excrete tubercular matter, excepting in those cases where signs 
of disease were apparent after death. It is only when the matter exists in 
the blood to such an extent that the intestinal follicles are spoiled in the at- 
tempt to eliminate it that appreciable lesion can be discovered. And this 
membrane can no doubt excrete it for a long time, and in considerable quan- 
tity, without any such result taking place. Just as in slight biliary obstruc- 
tions, the colouring matter of bile is exuded from the kidneys, mucous mem- 
branes, &c, before it accumulates in sufficient quantity in the blood to be 
deposited in the textures generally. 

There is no one of the mucous surfaces which may not thus excrete tubercular 
matter. The frequency with which discharges take place from the eyes and 
ears of scrofulous children is no doubt owing to the elimination by the mem- 
branes lining these parts of tuberculous matter. This discharge only requires 



1 



114 Troy, Nature and Cause of Tubercular Deposits. [July, 

to have its watery, or, to speak more properly, its absorbable* parts removed 
to constitute genuine tubercle. 

Andral relates a case in which it is certain that this matter was secreted 
from the membrane lining the prepuce, in a man having phimosis. 

Any disease of one of the mucous surfaces, as inflammation, by diminishing 
or suspending its excretory power, will throw an additional burden upon the 
portion which remains sound, besides leading to a deposit in the inflamed part, 
in consequence of the absorption of the liquid portion during the stagnation 
of the blood which takes place. 

Consumption of the lungs frequently does not manifest itself, in constitu- 
tions in which there is an evident predisposition to it, until after an attack of 
this description. 

"We have often seen cases of pulmonary phthisis commence during con- 
valescence from gastro-enteritis. Before the attack of the intestinal inflamma- 
tion, the patients had no cough, nor was there any symptom to make one ap- 
prehend in them the existence of a pulmonary affection." — Andral' s Medical 
Clinic, vol. ii. p. 232. 

Inflammation of the lungs themselves is still more apt to be followed by a 
deposit of tubercular matter than inflammation of any other organ. It acts 
both by diminishing the excreting power of their mucous membrane, and by 
inducing a stagnation of the blood, by which the absorption of its watery parts 
is facilitated. It is in this latter way that the deposit is so often left among 
false membranes and the other products of inflammation. A deposit having 
once formed in the lungs, it is easy to see how much more difficult it would 
be to get rid of it than if it had occurred in the parietes of the alimentary 
canal, or in any part of the urinary apparatus, excepting perhaps in the cor- 
tical structure of the kidney. 

In all inflammatory diseases, the calls upon the mucous membranes are 
greatly increased by the dryness, harshness, and constriction of the skin, de- 
noting partial suppression of its function. This is the case also in fevers, 
and still more so in the exanthemata, all of which hasten the progress or de- 
termine the development of tubercles. The peculiar ill effects of measles is 
explained by its not only involving the skin, but also the bronchial and ali- 
mentary mucous membranes. It is doubtful if any disease affects an equal 
extent of dermoid tissue, and no one certainly is so apt to be followed, in the 
predisposed, by phthisis. 

The lymphatic glands are said by Louis to be only second to the lungs in 
the frequency with which they are involved in tubercular disease. I do not 
believe, however, that they are ever attacked primarily, or, if so, only in those 
extremely rare cases where the matter abounds in the blood to such an extent 
that it may be deposited in any tissue, like the colouring matter of bile in 
jaundice. Their secondary implication is very easily accounted for : inflam- 
mation taking place in the membrane from which the effusion is taking place., 



* I mean by the veins; the entire matter may be absorbed by the lymphatics. 



1852.] Troy, Nature and Cause of Tubercular Deposits. 115 

it is arrested and absorbed by the lymphatic vessels, and carried to the nearest 
gland, where it is retained like any other foreign matter introduced into these 
vessels. 

In the lungs, owing to their anatomical structure, the effused matter is 
presented in a condition favourable for absorption without the agency of in- 
flammation. Hence the frequency with which the bronchial glands are affected 
with tuberculosis. In some rare cases, all the effused matter is taken up, and 
the glands alone are found diseased, the lungs being perfectly healthy. (An- 
dral and Carsicell.) 

But though inflammation does not seem to be necessary to induce tuber- 
culosis of the bronchial glands, they are nevertheless much more certainly 
affected when it does occur. Inflammation seems to increase the activity of 
the lymphatic system in a remarkable degree. 

The mesenteric glands are, I believe, never the seat of tuberculosis except- 
ing in the course of enteric inflammation. This latter may, however, be very 
slight, and leave no trace of its existence in the dead body, though usually 
indications of its presence may be detected. 

The frequency with which the lymphatic glands of the neck are affected is 
owing, I believe, to their being the only superficial ones (except those of 
the groin) whose vessels arise from the surface of mucous membranes. 

Inflammation of the gums from teething, a carious tooth, or from any other 
cause, eruptions around the mouth from gastric irritation, or any inflamma- 
tion of the conjunctiva or external meatus of the ear, may give rise to ab- 
sorption of tubercular matter by the lymphatic vessels which are so plenti- 
fully distributed upon these parts. The inflammation of a single Meibomian 
gland will often cause the tumefaction of the glands situated on the side of 
the neck. 

After a deposit has taken place in a gland, there is no need to suppose that 
it can increase only by the absorption of new matter. As in other situations, 
tubercle may here attract its own material from the blood, and continue to 
enlarge, even though the membrane, from which it was originally absorbed, 
may have resumed its healthy action, or even after it has been completely 
destroyed, as in the case from Andral, referred to above, where the effusion 
was upon the prepuce. 

This appears to me much more simple than the explanation usually given, 
that inflammation is excited in a gland, and assumes the tubercular character 
from the peculiarity of the diathesis. 

When suppuration takes place in a scrofulous gland, and it discharges its 
contents externally, it forms a ready outlet for more of the excretion ; its 
being constantly poured out by the pyogenic membrane which lines the fis- 
tulas which penetrate the gland prevents the occurrence of the healing pro- 
cess. Tubercular affections of the lymphatic glands are much more common 
in children than in adults, in consequence of the greater activity of their 
lymphatic systems, or perhaps from the greater frequency with which their 



116 Troy, Nature and Cause of Tubercular Deposits. [July- 

mucous membranes are inflamed. There are cases where the matter of tuber- 
cle is effused upon other tissues than the mucous, but always in those in 
which pus or other morbid products are usually deposited, as the brain, inter- 
muscular cellular tissue, &c. These cases only go to prove that tubercle is a 
foreign matter deposited from the blood, but throw no light on its nature. 

It is hardly necessary to state that my only aim in this essay is to direct 
the attention of the profession to the view I have advanced of the pathology 
of tubercular deposits, and not as a complete treatise on the subject. I have 
thrown together the most prominent features of what I believe to be the true 
pathology of tuberculosis, leaving it to others to accumulate the evidence cal- 
culated to establish or disprove its truth, and to apply it to the explanation of 
all the leading phenomena connected with, or arising out of the deposit of 
tubercular matter in the several tissues aud organs of the body. 

I think I have shown that the nature and importance of the secretion of 
the skin are sufficient to give rise by its deficiency of suspension to the accu- 
mulation of tuberculous matter in the blood ; that in those individuals in 
whom consumption is hereditary, there is often a congenital deficiency of the 
sebaceous follicles ; that the disease can at any time be produced or aggravated 
by causes which depress their action ; and prevented or relieved by causes 
which exalt it; that the only well-ascertained product of the secretory ac- 
tion of these follicles is found in large amount in tubercle ; and that it is 
deposited in precisely such situations as we would be led to suppose, upon 
general principles of physiology, that the retained secretions of the skin 
would be. 

This theory has at least the merit of being consistent with all the pheno- 
mena of the disease ; of explaining the action of the causes which produce it 
upon established physiological principles; of explaining its hereditary trans- 
mission by the same law which causes children to resemble their parents ; of 
redeeming our practice from empiricism, and making it rational, and most 
important of all, of explaining the efficiency of hygienic means, and thus im- 
pressing the necessity of them more effectually than any amount of mere 
recommendation could do, even though this were founded upon the largest 
experience. It differs from the views of Andral and Carswell, by showing 
the nature and source of the "peculiar secretion," of which they speak; and 
seems, upon the whole, far more simple and definite than any other yet ad- 
vanced. 

"Whiteville, Columbus County, North Carolina, 
March, 1852. 



1852.] 



Kneeland, Phosphate of Lime in Phthisis. 



117 



Art. X. — Phosphate of Lime in Phthisis. By S. Kneeland, Jr., M. D. 
Read before the Boston Society for Medical Improvement April 26, 1852. 

The great number of remedies which have been recommended, tried, and 
found wanting in the treatment of phthisis, justifies the medical world in 
looking with distrust upon any new article which may be advanced as pos- 
sessing power against this fatal disease ; but, while we are incredulous, we 
may also be hasty and unjust to condemn, before a careful examination and 
a systematic trial have enabled us to judge knowingly in the matter. 

Without pretending that the phosphate of lime is of any advantage in the 
treatment of phthisis, it seems to me that there are chemical and physiological 
reasons why it may be beneficial in this disease j at any rate, there is a singu- 
lar coincidence, to say the least, between this remedy and the product which 
has been generally considered as nature's attempt to cure by a chemical 
transformation of tubercle. 

Both albumen and fibrin, the chief original components of the tissues, 
contain about two per cent, of phosphate of lime ; liquid albumen dissolves 
this salt, which may be separated from it in its coagulated state; so fibrin, 
when burned, leaves a portion of this salt. It is generally agreed by physio- 
logists that the deposition of tubercular matter is a perverted or abnormal 
form of the process of nutrition, so that albuminous tubercle is deposited in 
the tissues instead of the latter being replaced by organizable fibrin. Now, 
though this conversion of albumen into fibrin, necessary for normal nutrition, 
may be more of a vital than a chemical process, and though albumen and 
fibrin have the same chemical constitution, and, so far as we know, the same 
proportion of phosphate of lime, still this salt may have an important influ- 
ence on the form which the tubercle may assume. From an essay in the 
London Lancet, on the " Physiology and Pathology of the Phosphate of 
Lime/' it appears that this salt exerts a singular influence over the formation 
of cells; and hence it was recommended and used with success in many de- 
praved conditions of the system ; keeping up a normal nutrition and counter- 
acting emaciation. This is in accord with the condition of the blood in 
phthisis, which, according to Andral and G-avarret, though it may be rich in 
fibrin, is deficient in plasticity, forming what is called cacoplastic or aplastic 
tubercle, according to the presence or absence of organization in this product. 
By the above terms are expressed the two great forms of tubercle, viz. : 1, the 
"semi-transparent, miliary, gray, and tough yellow forms," in which there 
are distinct traces of organization in the form of cells and fibres ; which, how- 
ever, never reach any higher organization; hence termed cacoplastic. 2. The 
" opaque, crude, yellow" tubercle, which is absolutely structureless, resembling 
a granular albuminous coagulum ; hence called aplastic. The former has a 
tendency to contract, the latter to soften. If, then, this influence of phos- 



118 Kneeland, Phosphate of Lime in Phthisis. [J u ty? 

phate of lime over cell-growth be established, it does not seem unreasonable 
to connect the different degrees of the plasticity of the blood, and the different 
degrees of the organization of tubercle, with the variable amount of this salt 
in the circulating fluid. I am not aware that any chemical analyses have 
been made to determine this point; though the difference might be too 
minute to be detected by the minutest investigations at present practicable. 

There is another point of view from which it is interesting to examine phos- 
phate of lime in connection with tubercle; that is, in connection with the 
cicatrices and calcareous formations so often found in phthisis, and usually 
recognized as an attempt at cure on the part of Nature. 

Laennec long since expressed the opinion that tubercular disease may be 
arrested in its second stage by transformation into calcareous matter, or by 
cicatrization. The fact of these concretions cannot be denied ; M. Koger found 
them in the lungs of old people, fifty-one times in one hundred, in subjects taken 
at random. The same author (Archiv. Gen. de Med., 1839) shows the pas^. 
sage from one to the other, from tubercle to a chalky concretion, and from 
this last to a calcareous mass; and, what he considers remarkable, the trans- 
formation begins at the centre. M. Valleix has seen the three stages, in con- 
centric layers, in the same tubercle ; a calcareous centre, a cretaceous layer 
outside of this, and a layer of crude tubercle externally. 

The chemical analysis of crude unorganized tubercle is: animal matter 
98 parts in 100 ; muriate of soda, .15; phosphate and carbonate of lime, 1.85; 
and traces of oxide of iron. In the concretions the chemical elements are the 
same as in tubercle, but their proportions are very different ; while tubercle 
has 98 parts in 100 of animal matter, the concretions have only 5 ; the latter 
are principally made up of phosphate of lime, while tubercle has only two per 
cent, of it, like albumen and fibrin. This looks very much like a calcareous 
impregnation of tubercle, or a chemical transformation from an excessive 
deposit of phosphate of lime; and this without the softening and discharge of 
the tuberculous matter. 

The cicatrices, seen often at the summit of the lungs, were also considered, 
even by Laennec, as efforts of nature to heal the excavations in the lungs by 
depositing in excess the phosphate of lime necessary for the formation of 
the cartilage of which the cicatrices of the lungs are usually formed. At any 
rate, we find cicatrices of caverns at the summit of the lungs, after the dis- 
charge of the softened tubercle. The lining false membrane becomes more 
and more cartilaginous, the walls are brought into contact, forming a 
fibro-cartilaginous fistula or hollow cicatrix, which may or may not contain 
concretions of phosphate of lime; though, if permeable to the air through any 
bronchial tube (of which the openings into the cavities are usually obliterated), 
we should expect to find this salt, which is almost always present in the fluids 
of sinuses and fistulae. communicating externally. According to Louis, these 
cicatrices are a rare and happy termination of tubercular cavities. 

Many cases are on record of individuals having recovered after having pre- 



1852.] 



Kneeland, Phosphate of Lime in Phthisis. 



119 



sented unequivocal signs of phthisis, and who, dying years afterwards of an- 
other disease, have presented these calcareous concretions at the summit of the 
lungs. In view of such cases, it was asked by Andral, many years since, " Is 
it not possible that, the calcareous phosphate having become predominant, the 
secretion of tubercle may be arrested ?" As it were, extinguished? 

As almost all the cases of cicatrization and calcareous transformation have 
been found in old persons in whom tubercles are rare and few in number, it 
may be objected, with Louis, that there is no proof that these few tubercles, 
of which we find the traces and alterations, were not developed at an advanced 
age, when the vital power of the organs is diminished, and when such depo- 
sits are common in other parts of the system ; making phthisis, as far as these 
facts go, curable only at the age when it is least common and least to be feared. 
It may be answered that these pulmonary concretions are different from the 
ossifications common in old people ; they present no traces of a fibrous character, 
as do the latter; they also contain only five per cent, of animal matter, while 
the latter contain thirty-five per cent. 

We find, then, phosphate of lime, so essential to vegetable life, playing a 
very important part in the production of animal-cells, and in this way influ- 
encing the amount of organization in tuberculous growths; we find it in the 
cicatrices of pulmonary caverns — and especially we find it in the concretions, 
which are acknowledged to be transformed tubercle, nature's successful attempt 
at the cure of phthisis. We hence naturally inquire, cannot medical art trans- 
form a tubercle, and cicatrize a cavity ? 

Allusion may be made here to an interesting case of resolution of tubercle 
under the use of cod-liver oil, reported by Dr. Chas. E. Ware, to the Society, 
Aug. 25, 1851, and published in its " Extracts," p. 171. In this case, which 
proved fatal from disease of the bladder, there were found in the upper lobes 
of both lungs, " numerous cretaceous masses, some of them quite large, with 
the substance of the lung contracted and hard about them ; no crude tubercles 
or cavities." The patient was exceedingly reduced, and continued the use of 
the oil for a four months, all the time failing, before she began to experience 
any benefit." 

This patient was only thirty-five years of age, showing that these cretaceous 
masses may, and doubtless often do, occur in other than old people. He 
alludes to three other young women, in whom there was hardly a doubt as to 
the existence of tubercle, who took the oil for nearly as long a time, and with 
great improvement. 

In this case, cod-liver oil was used, and not phosphate of lime; but cod-liver 
oil contains phosphorus in larger proportion than it does iodine, to which last 
substance the efficacy of the oil was formerly supposed to be due; this phos- 
phorus, meeting lime in the system, may thus have been instrumental in trans- 
forming the tubercles. How much of the cerebral and urinary trouble may 
have been caused by this minute portion of phosphorus, long continued, may 
be worthy of consideration, especially if the well-known action of this substance 



120 Kneeland, Phosphate of Lime in Phthisis. [July? 

on the nervous and genito-urinary system be remembered; and if similar 
symptoms should be observed in other cases of the administration of the cod- 
liver oil, or the phosphate of lime, singly or combined. 

Of the influence of cod-liver oil, in causing a deposition of phosphate of lime 
in the system, we have ample evidence from its effects in rickets; indeed, it 
was from its good effects in this disease that the medical profession adopted it 
from the Baltic fishermen, about 1824. In rickets, there is a deficiency of 
phosphate of lime in the bones to such an extent often that they may be bent 
almost like wax, as many have seen in the wards of M. Trousseau; the use of 
the oil for a few weeks acts like magic in giving solidity to the bones by the 
deposition of the required phosphate of lime; and this we think it can only 
effect by the phosphorus it contains. 

The case of Dr. Ware's would also point to a long-continued use of the 
phosphate of lime, before deciding on its uselessness; his patient used the oil 
four months before she perceived any benefit from it. 

For the reason that the carbonate of lime enters into the composition of these 
concretions; and, from Valleix's statement above alluded to, possibly forms 
the first and transitory stage of transformation into the phosphate, this salt 
may also be of use; it would seem that the carbonic is replaced by phosphoric 
acid in the completely transformed tubercle; if the transformation even into 
the carbonate of lime, supposing this anterior to the deposition of the phos- 
phate, could be in any way favoured, a great point would seem to be gained 
in the aplastic tubercle. And, if the phosphate can add to the organization 
of tubercle, by increased cell-growth, and thus favour contraction and cicatri- 
zation (of which as yet we have not sufficient data to judge), we have certainly 
great cause for hope. 

It really seems that a careful examination and systematic trial, in the direc- 
tion to which the attention of the profession is now turned, promise to reveal 
important facts, if not to discover how to prevent and even to cure this fright- 
ful disease. We know, possibly, what we want, and that is phosphate of lime; 
but we do not know how to get this substance exactly where we want it. 
Phosphate of lime, being insoluble in water, and very slightly soluble in liquid 
albumen, may very likely not be the form, however pure and fine it may be, 
in which it can best be introduced into the system ; it may be better to sepa- 
rate its elements and give the phosphorus with or without lime, or phosphate 
of lime with cod-liver oil ; or it may be better to obtain its introduction by 
the decomposition of other salts. Questions like these, and the effects it may 
have on the nervous, osseous, and vascular systems, on the urinary and other 
secretions, &c. &c, can only be determined by future investigations, perse- 
veringiy made. 

Boston, May 1852. 



1852.] Mitchell, Observations on Generation of Uric Acid. 



121 



Art. XI. — Observations on the Generation of Uric Acid, and its Crystalline 
Forms. By S. Weir Mitchell, M. D. [With five woodcuts.] 

The part played by uric acid in the healthy urinary secretions is so import- 
ant, and its relations with the morbid states of that secretion so interesting, 
that it has been looked at with great attention, and lately studied in every 
point of view. 

Deeply connected with its therapeutics, and of kindred interest, are its nu- 
merous and beautiful crystalline forms, surpassing, in elegance of figure, in 
colour and in variety, all other urinary crystals. 

These forms of uric acid vary so greatly, that it would naturally be sup- 
posed that their distinctions of shape depend upon perceptible varieties in 
the chain of healthy or morbid processes which give rise to their formation, 
and that, by careful study, we might be able to trace out such relations, and 
make use of them for therapeutical and nice diagnostic purposes. Thus far, 
however, such has not been the case; and although some such alliances of 
cause and effect are in the highest degree probable, we have not been so for- 
tunate as to elucidate them to any very valuable or available extent. 

We are aware of the change from rhombs to squares, which occurs in the 
progress of old cases of lithuria ) and we are also aware of the fact that a 
tendency to aggregate in masses, as seen without the bladder, is only too in- 
dicative of a similar disposition towards aggregation within it, and, conse- 
quently, to the formation of calculus. 

At present, I would desire to call attention to a point in the crystallography 
of uric acid, which has attracted considerable attention, and given rise to seve- 
ral explanations. These views are mainly theoretic, and are unsupported by 
what may be termed crystalline analysis, on which I have chiefly relied in 
obtaining the results detailed in this paper. 

According to Golding Bird, all the varieties of form, so constantly met 
with in uric acid, are referable to the rhombic prism. It is singular that 
these alone, of all the forms, we have not been able to reproduce, out of the 
body, by the addition of an acid to urine. Dr. Bird very properly states that 
the beautiful fleurs-de-lis crystals, which he has figured, are cubes or rhom- 
boids, with indented edges. I have sometimes obtained these so slightly 
indented as to make them look almost identical with the primitive form. 

Another and a very frequent variety, of crystalline shape, is the lozenge, 
found very often in natural deposits, and almost invariably present in the 
sediment of uric acid, caused by the addition of a few drops of hydrochloric 
acid to a large quantity of urine. When these lozenges are very thin, they 
present to the observer their elliptical faces; but when of greater thickness, 
they offer the appearance of cylinders, brilliantly lighted in the middle, and 
shaded at the two extremities. At times, and in a few specimens, two lozenges 




Fig. 4. 



Fig. 5. 



1852.] Mitchell, Observations on Generation of Uric Acid. 123 



appear to have formed at right angles to one another, and to have become 
perfectly united during the process of formation. Such crystals offer a very 
beautiful starlike form, varying in thickness and in size, like the lozenges 
from which they derive their existence. This variety closely resembles the 
fleur-de-lis crystals. I have sometimes noticed, both in these and in the sim- 
ple lozenge, a long spine, like an acute pyramid, projecting from one of the 
extremities of the lozenge, and resembling a marking of the same shape as 
that which is often seen upon the surface of the lozenges, and which has been 
already described and drawn by Bird. (See Figs. 1 and 2.) 

The last variety to which I shall now allude, is the oblong plate, whose pe- 
culiar and beautiful markings have attracted so much attention, and received 
so many explanations. (Fig. 5, a.) Before referring to this, I wish, however, to 
describe some similar and equally curious markings which are, I believe, un- 
described, and which belong to the lozenge-crystals above mentioned. I hope, 
by these means, to explain satisfactorily the crescentic curvatures of the tabu- 
lar crystals, and to cast some light upon the primary forms of uric acid de- 
posits. 

When a well-formed lozenge is placed upon its side so as to present to the 
eye the appearance of an oblong figure, two distinct and very perfect cres- 
centic marks are seen commonly touching one another at their convexities, 
and including within their curves the greater mass of the crystal to which 
they belong. (Fig. 3, a, b.) These markings rarely show well in such crys- 
tals as belong to natural deposits, and in most cases are entirely invisible, or 
to be seen only after long digestion in Canada balsam. 

Having been much struck by this resemblance to the curves on the faces 
of the tabular variety, I have been at some pains to ascertain the cause of the 
likeness. After numerous experiments, I believe I am able to explain these, 
as well as some other peculiarities of uric acid deposits. The very small size 
of the bodies with which we have to deal, as well as the necessity of conduct- 
ing our researches under the microscope, renders it impossible to avail ourselves 
of the methods applicable in ordinary crystallography, and I was therefore 
obliged to use certain agents not generally employed. 

In the course of these studies, I placed in each of four test-tubes about 
half an ounce of urine. To the first of these, I added one drop of hydro- 
chloric acid; to the second, five drops; and to the third and fourth, ten and 
thirty drops respectively. At the end of thirteen hours, I examined the de- 
posits in all the tubes. No: 1 presented a few very minute lozenges, pale, 
thin, and in many cases looking like little spheroids. Nos. 2 and 3 contained 
larger and thicker lozenges, while No. 4 presented, not only large lozenges, 
but a few well-formed tabular crystals. I now removed a drop of fluid from 
No. 1, and placed it on a slide to dry. As evaporation went on, the acid 
naturally became more concentrated, and when, after drying it, I moistened 
the plate with water, and placed it under the microscope, I was surprised to 
see the field covered with singular little crystals. These were shaped precisely 



124 Mitchell, Observations on Generation of Uric Acid. [July? 

like an hourglass, or like two half spheres, placed with their convexities in 
contact. The outlines of these bodies resembled precisely the marking on 
the large lozenge-crystals, and although varying a little in their degrees of 
curvature, were of the same type throughout. I next observed that some of 
them had the space between the two half spheres filled more or less by what 
I have since concluded to be minute acicular crystals. In a few, this space 
was completely occupied, and the general form was then seen to be a lozenge, 
with curves due to its primitive character, and with elliptical surfaces upon 
the two ends. In the course of time, most of the crystals underwent a like 
change, and the hourglass form disappeared altogether. (See Fig. 3, c.) I 
have retained some of these crystals, but I have not yet been able to repro- 
duce others of a like character, although I have made many efforts. 

I next placed a few well-formed lozenges under the glass, and, adding a drop 
of diluted nitric acid, watched the process of solution. In a few moments, 
the acicular structure between the two curves began to give way, being at- 
tacked most easily on account of its loose composition. While it melted 
rapidly, the denser primitive forms remained untouched, and, finally, the crys- 
tals presented a beautiful hourglass shape, encircled in some cases at the 
apices of the primitive forms by a black band. This appearance was due to 
the irregular and uneven surface of the yielding fibrous structure, which re- 
fracted the light so as to appear black. In others, the hourglass was left 
naked, and, in some, the corners were rounded off by the continued action of 
the acid. (See Fig. 4, a, b.) 

In my final experiment, I placed some lozenges of uric acid in water, and 
heated them slowly. On placing these beneath the microscope, the surfaces 
which represent oblongs were seen to be marked with dark lines showing 
very beautifully the form of the acicular crystals as they lay agminated 
about the primitive nuclei. (Fig. 4, c.) I do not rely greatly on this appear- 
ance, since I have not found it uniform, the crystals often becoming striated 
in the other direction. It will thus be seen that little doubt is left as to the 
origin of the curves on the lozenges, and I believe I can show that the tables 
owe their marks to a like cause. From repeated observation, I have come to 
the conclusion that they are in fact large lozenges, of no great thickness, but 
having an oblong or square surface, on which are seen the marks of their 
primitive form, and around which the acicular crystals have collected, clothing 
it completely. Upon either extremity, a cluster of such needles has formed 
perpendicularly to the elliptical face of the crystal, and can often be broken 
off in mass from the main body. (See Fig. 5, a, 6.) 

I have thus obtained a knowledge of the form of these crystals by synthesis, 
by analysis, and by the aid of heat. 

On reference to Bird on Urinary Deposits, it will be seen that he sus- 
pected these crystals to be compound, and indeed suggested what he believed 
to be their ultimate form, which he referred to the union of two acute rhombs 
superimposed laterally. He also states that Dr. Burton, of Walsall, ascribes 



1852.] 



Gardner}- Cases of Operative Midwifery. 



125 



them to the union of two rhomboidal (?) figures, surrounded by acicular 
crystals; an opinion which is very nearly correct, but for which he gives no 
reasons. However arrived at, this view is very ingenious, and very close to 
the truth. Neither of these gentlemen seems to have noticed the curves on 
the lozenges, which gave the key to those upon the tabular variety. 

It is highly probable that observation of some of these curious hourglass 
forms, misled Dr. Fricke, of Baltimore, into the belief that the dumb-bell 
crystals of oxalate of lime were forms of uric acid, with which they have, 
in reality, very little analogy. In the early part of this paper, I have alluded 
to a stellar form of uric acid, the result of the conjoined growth of two 
lozenges placed at right angles to one another. I may add, that they some- 
times exhibit beautiful markings when rolled on their sides, and even show 
the indentations resulting from the ultimate forms of their component lozenges. 
(See Fig. 5, c.) 

There are some other remarks in connection with the crystallography of 
the urine which I would wish to add, but I reserve them for a future com- 
munication. 



Art. XII. — Report of Cases of Operative Midwifery, with the particulars 
of a novel operation. By Augustus K. Gardner, M. D., Fellow of the 
Mass. Med. Soc, N. Y. Acad, of Med., District Physician of N. Y. Lying- 
in Asylum, &c. &c. 

The following cases, in most of which I have been called upon to operate 
for others, have occurred since January 1, 1852, and, as they contain some- 
thing peculiar (and in one of which I performed a novel, and I will venture 
to predict for the future, a common, operation), I have drawn them off from 
my note-book, with some slight amplification. 

Case I. — Delivery by Forceps — Elongated Os. — January 1, at 6 P. M., I 

was called to see Mrs. , 17 Doyer Street, a large, muscular, healthy 

woman, in her first confinement. Reports herself twenty-two years of age, 
but apparently more. She was taken ill on Monday, December 29, when 
she had severe pains, and on Tuesday states that the membranes ruptured. 
She sent for Mr. Austin, a young student of medicine, of considerable attain- 
ments, under whose care I found her on Thursday evening. The os was 
apparently entirely effaced • but, on careful examination, it was found that 
it was dilated to about the size of a shilling, while the neck, thin and smooth, 
lay closely upon the presenting vertex. The pains were exceedingly strong 
and propulsive. 

Friday, 10 A. M. The patient had taken one grain of opium every hour 
during the night, but without causing sleep, or quieting, in any apparent 
degree, the pains. Find the os dilated to the size of a teacup-top, edges hard 
and like a cord. Head descended a little. 

12, midnight. Pains continued during the day with no apparent change. 
No. XL VII.— Jult ; 1852. 9 



126 Gardner, Cases of Operative Midwifery. [July? 

Saturday, 9 A. M. The os somewhat more dilated, but not enough to 
allow the head to pass; edges still "cordy." Pulse considerably accelerated, 
perineum very firm, and vulva dryish and hot. 

12 M. The os offered little or no impediment to the advance of the head, 
which presented in 1st Baudelocque. 

5 P. M. The labour being still restrained, Dr. Simmons being present, 
with Mr. Austin, I proceeded to administer chloroform ; and applied the short 
forceps, and without much difficulty affixed them to the head, though im- 
peded somewhat by the delirious movements of the patient when not com- 
pletely under the influence of the anaesthetic. Considerable force was 
requisite in the traction, so much as to bend one of the blades of the forceps 
(which I had repeatedly used previously) nearly straight. A healthy and 
vigorous female child was safely delivered, who viva voce immediately informed 
us of the fact. 

It being subsequently necessary for the removal of the placenta to intro- 
duce the hand, I found that it had entered a cul-de-sac, which prevented fur- 
ther advance. On investigation, this was found to be caused by the os uteri, 
thin and elongated to nearly four inches, and that the hand had passed 
external to it, and between it and the vagina posteriorly. 

The woman had no subsequent inflammation, and was up on the fourth 
day. On the second day after, while the child was in the hands of an attend- 
ant, it was taken with a slight convulsion, scarcely noticed at the time ; it was 
subsequently placed on the arm of the mother, where it nursed vigorously 
until both fell asleep. On the mother's waking the child was dead. As I 
felt a slight crack when the instrument slipped, from the bending of the blade, 
I presume that from thence may be traced the cause of its subsequent early 
death. JSTo post-mortem was permitted. 

Case II. — Ineffectual Attempt to apply the Forceps — Delivery effected l>y 
Craniotomy , &c. — Peritonitis — Copious Flooding on the sixth day. — Janu- 
ary 12, 2 P. M. Was called to see Mrs. S , 41 Anthony Street, by Mr. 

Mattheson, of Syracuse, N. Y., an advanced student. Patient was taken ill 
at 8 o'clock the previous evening. She was previously the mother of two 
children, one dead-born. She was a weakly woman, aged about 40. The two 
rooms which she 'occupied, in common with two other families, containing 
numerous children, were filthy in the extreme, and the smell was most nau- 
seating. 

On examination, the presentation was found to be the occiput, but the posi- 
tion was not so easily diagnosticated. It appears to be the occiput to the left 
iliac posterior — the forehead thus under the pubis and to the right, but on 
delivery it was found reversed — the occiput being to the right iliac anterior. 
There had been no advance in the progress of the labour since 5 A. M., the 
membranes having ruptured the preceding evening. Pains were constant, but 
of no expulsive power. Pulse rapid, and the general appearance of the wo- 
man bad. 

I immediately proceeded to apply the short forceps. "With considerable 
difficulty I passed each branch over the sides of the head, but was unable, 
without using unjustifiable force, to make them lock. I in vain removed 
each branch and reintroduced them, till finally and reluctantly I gave up the 
attempt. 

At 5 P. M., I proceeded to open the head, and delivered a female child, which, 
without the brain and blood, weighed eight and a half pounds. The placenta 
was delivered by the pain which expelled the child. 



1852.] 



Gardner, Cases of Operative Midwifery. 



127 



At the time of delivery the abdomen was much tumefied, and tender to 
the touch. Peritonitis soon ensued. She was carefully treated by the stu- 
dent in attendance, under the direction of Dr. Alonzo Clark. The opium 
treatment was resorted to, but with little hopes of success in the horrible 
filthy room in which she lay. Still, on the fifth day, she appeared much 
improved- the tumefaction and tympanitis were subsiding, tenderness lessened, 
the pulse and respiration improving, when, on the evening of the sixth day, 
Mr. Mattheson, who had not in his assiduous attention been absent from her 
side more than two hours at a time since her attack, on coming into the room 
found her almost pulseless, and bathed in blood from an uterine hemorrhage, 
which had just supervened. Brandy and stimulants temporarily benefited; 
but in the course of the night, without any apparent subsequent hemorrhage, 
she suddenly died. No post-mortem was permitted ; but the impression was that 
the treatment would have been effectual, had not this flooding, so unusual at 
this late period, supervened. Dr. Clark will doubtless allude to this case, in 
the report of cases treated by opium in heroic doses ; and I, therefore, have 
not entered particularly into the minutiae. 

Case III. — Case of Obstinate Rigidity of the Os Uteri, overcome only by 
dividing it, by cutting through either side. — January 18. Was called at 6 

P. M., by Dr. Anderson, to see Mrs. C , 675 Water Street, with her first 

child. The patient was a large, muscular woman, and apparently about 
thirty years of age, though stating herself to be considerably younger. She 
had been in labour when I saw her twenty-four hours, and there was now no 
apparent advance in the labour during this time. The os continued rigid, 
notwithstanding that she had been bled 3xvj, and had taken nauseating doses 
of tartar emetic, and several grains of opium. The pains had been frequent 
and strong. 

On examination, per vagina, find the vertex presenting, os dilated to the 
size of a teacup-top, exceedingly firm and hard. At my suggestion, Dr. A. 
reopened the vein in the arm, and extracted ^xvj, producing some dizziness 
of the head, but with no apparent effect upon the os. After remaining two 
or three hours without noticing any change, we administered two grains of 
opium, in a half hour another grain, and in another quarter of an hour a fourth 
grain, and left, with directions to repeat a grain every half hour until sleep ■ 
was produced. She had felt no movement of the child during the day. 

19th, 7 P. M. Patient took eight grains of opium before any effect was 
obtained, and slept till 3 A. M., the pains then recommencing with full vigour ; 
which now have much diminished in force and frequency, indeed are but little 
expulsive in their character. Some chills are reported as having occurred dur- 
ing the day, and the patient's mind is somewhat affected — slight involuntary 
action of the muscles of the extremities. The os has dilated but little, and 
the edges are still thick and rigid. Vulva hotter and much drier than yes- 
terday. The friends are urgent to have some operation performed, and Dr. 
Anderson proposes that the head be opened. 

The only reason apparently why the labour does not advance is the rigidity 
of the os, and if that could be overcome it appears that the labour would go 
on to a speedy termination. But how to effect this desired result? All the 
usual modes had been fruitlessly exhausted. Mechanical dilatation by the 
fiugers was impossible. A vigorous pain may perhaps lacerate the os. 
Lacerations of the os uteri are frequent. May it not then be cut? I remem- 
bered my previous case, where I divided the os in labour, when by a prolapse 
it was entirely out of the body (see a case in this Journal, October, 18^(3), 



128 



Gardner, Cases of Operative Midioifery. 



and determined to divide the os. The determination made, the act was easily 
accomplished. With a long pair of curved uterine scissors I made an incision 
laterally upon one side three-quarters of an inch long, on the other one and 
a quarter inches. Yery slight hemorrhage ensued. The pains were revived 
by an infusion of secale cornut., and in about three hours a large putrid female 
child was expelled. The cord was so weak that it immediately separated from 
the placenta, which was delivered by introducing the hand, with little diffi- 
culty. The labour was delayed after the operation, by the head remaining 
nearly an hour on the perineum, after passing through the divided os, and 
the body not being delivered without much strenuous assistance. The occiput 
was to the right iliac anterior. 

So rarely has any operation of this kind been recommended in treatises on 
midwifery, as taught in the schools, that I was not aware that it had ever be- 
fore been performed. Even Dr. Churchill, who is generally so complete, does 
not mention it in his History of Operative Midwifery, and in his Theory and 
Practice of Midwifery; he says, paragraph 397, "I believe we shall rarely, 
if ever, fail in softening the cervix by some of the remedies I have recom- 
mended, and I must beg leave to enter my protest against more active inter- 
ference." 

Ramsbotham speaks in favour of the operation, though he evidently had 
never performed it. He writes, in his Obstetric Medicine and Surgery, 
" I should prefer operating on the os uteri, unless indeed there were present 
the most unequivocal signs of the child's death; and I should even hope for 
the patient's survival for some time, being cheered by the result of the last 
case detailed in the note, in which I have not the slightest doubt that a lacera- 
tion occurred." 

Blundell says : " Under all circumstances, if you must have recourse to 
instruments at all, you had better at once have recourse to the perforator." 

Baudelocque says : " After a convenient delay, to ascertain that the efforts 
of nature cannot overcome the resistance, and the administration of proper 
methods to relax it, it must be cut in several places, as some practitioners 
have done. These incisions are preferable to rents, which might take place 
in it, and have never been attended with the same consequences." 

Dr. Dewees, quoting the above, thus remarks : " The success of this plan has 
been verified, in this country, as the case of Dr. Thomas Archer most satisfac- 
torily proves," where the " uterus, loaded with its contents, was pushed through 
the os externum ; * * * * he, accordingly, made three cuts in the uterine 
circle, * * * each about two inches long; * * * no unpleasant 
symptom followed." This case is evidently very similar to the one reported 
by me in 1846. 

Dr. D. also quotes Moschati, who made several incisions in the circle of the 
os uteri, 1827, with success. 

Dr. Murphy says : " If these means fail, it becomes a question whether we 
should wait for the death of the child, in order to remove it by the crotchet, 
or incise the unyielding cervix. The former practice involves a sacrifice of 
life, but generally secures the mother from the injurious effects which may 
follow. The latter may be the means of preserving the child, but if the in- 
cision lead to a laceration of the uterus, the mother is at once placed in the 
most imminent danger of her life. The fear of such a consequence, it ap- 
pears to me, has prevented any attempt being made thus to cut through this 
Gordian knot of difficult labour in its first stage; but whether this, like other 
operations, is only surrounded by chimeras of the imagination, which some 
bold spirit will dissipate, remains yet to be proved. Incision has been per- 



1852.] 



Gardner, Cases of Operative Midwifery. 



129 



formed without accident ; the same may happen again ; and I confess, in a 
case such as I have described to you, I should be more disposed to adopt the 
shorter course, in the hope of saving the child, than to wait until its death 
enabled me to remove it. This, however, is but an individual opinion, and 
needs support." 

My old instructors, Chailly and Cazeaux, have written with more fulness 
upon the subject. Chailly says: " Aussi si cet etat a resiste aux bains, a la 
saignee, h la belladonne, ce qui arrivera le plus ordinairement, on devra 
pratiquer des incisions sur les parties laterales de l'orifice, a l'aide du bistouri 
en croissant ou du bistouri droit boutonne, et mieux encore a l'aide des ci- 
seaux courbes sur leur tranchant, et conduits sur le doigt jusque dans le col 
uterin. II est utile, dans ce cas, de multiplier les incisions, pour qu'elles 
puissent fournir une assez grande dilatation, sans qu'on ait a craindre qu'elles 
ne se prolongent trop haut. C'est aussi pour eviter les consequences de ce 
prolongement, qu'il ne faut pas les faire a la partie anterieure et posterieure 
de l'orifice. En effet, prolongees dans cette direction, ces incisions pourraient 
interesser la vessie ou le rectum. 

u J'ai vu ce debridement de l'orifice suivi du meilleur effet, soit sur des 
femmes, ou la rigidite .pure et simple du col etait le seul obstacle, soit sur 
d'autres chez lesquelles les parties efcaient plus ou moins alterees. 

" Chez une jeune fille agee de dix-sept ans, qui vint accoucher a la clinique, 
le col a l'etat sain d'ailleurs, etait tellement rigide, qu'il ne ceda qu'aux in- 
cisions. L' enfant fut expulse en position occipito-posterieure non reduite. 

" Les incisions furent encore le seul moyen de rendre l'accouchement pos- 
sible, chez une femme agee, mere de dix enfans; le col etait tellement dege- 
nere que, de prime abord, il fut pris pour le placenta implants sur 1' orifice." 

Cazeaux writes from less experience : " Si l'orifice externe retracte est seul 
cause de la dimculte, on aura recours aux incisions multiples pratiquees sur le 
pourtour du col." 

An extract from a recent note from Dr. John H. Anderson will show the 
result of the operation. " I am happy to inform you that the Water Street 
case does well, and enjoys excellent health at present. On the sixth day 
after the operation, she sat up in her chair without any symptom threatening 
inflammation, and from that day progressed rapidly, which affords me much 
satisfaction in the novel treatment for such a case." 

Case IV. — Three Cases of Version. — January 23. Mrs. , a German 

woman with her second child, under the care of a midwife. I was sent for at 
11 P. M. No one in the room could speak English or French, and I could 
not hold any communion with them. The midwife, however, by signs, stated 
that the case was a footling presentation. On examination, the hands and 
cord were presenting, and the occiput resting on the pubis occipito iliaque 
gauche transversale. The cord prolapsing more and more, I immediately 
turned and delivered without difficulty ; a fine boy was born, which, with the 
warm bath and the inflation of the lungs, soon cried lustily. The right arm 
was swollen for some days, and looked very much like a dislocation of the 
radius, but disappeared without treatment. The woman did well. 

March 3.— At the request of Dr. Bishop, I saw a German woman, corner 
of Ludlow and Delancy Streets, some two days in labour; membranes rup- 
tured since morning. At 5 P. M., os fully dilated. The left hand presenting 
and the head felt to the left iliac. Proceeded to administer chloroform, and 
Dr. B. introduced his hand and attempted to gain the feet, but was prevented 
by the uterine pressure. I then introduced my hand, and found a marked 



« 130 



Gardner, Cases of Operative Midwifery. 



contraction of the antero-posterior diameter, caused by a projection of the 
promontory of the sacrum. Passing my hand, with some difficulty, through 
the ring caused by the contraction of the circular fibres of the uterus,' I 
reached the feet, brought them down, and speedily delivered the child, which 
gasped several times, but all attempts to restore it were unavailing. This 
woman was delivered of a dead child by forceps in Germany, and Dr. B. had 
previously delivered her, by turning for arm presentation, of a dead p child. 
The patient did well. 

March 26. — Mrs. J. M., 136 Mulberry Street, with her fourth child (two 
of them stillborn). She had been taken ill on the evening of the 24th, and 
was without a physician till this A. M. She was then seen by Dr. Hale, of 
Broome Street, who found that the membranes had been some time ruptured, 
and the hand presenting. He sent for Dr. Johnson, of the New York Lying-in 
Asylum, who called for me at 12 M. ; found the os fully dilated, the right 
hand and cord presenting and descended into the vagina, the head in the left 
iliac region. We proceeded to administer chloroform, and placing her in 
position; I introduced the left hand, and seizing one foot (after in vain at- 
tempting to return the prolapsed cord, as it was easy to return the hand and 
arm, and bring down the head), with some difficulty, turned and delivered 
a male child. All efforts to produce respiration were fruitless, although the 
heart beat for some time quite vigorously. The afterbirth was delivered by a 
second introduction of the hand, the flooding being quite severe. In this 
case, there was a most decided contraction of the antero-posterior diameter to 
from three and a half to four inches, resulting from the projection of the pro- 
montory of the sacrum. Mother did well. 

Case V. — Case of Placenta Prsevia. — February 11, I was called to Mrs. 
G., 178 Lawrence Street, with her tenth child at the seventh month. She 
had been taken with very copious flooding almost producing syncope. Examina- 
tion, per vagina, showed nothing. The os was entirely out of reach, and no 
portion presenting could be felt through the parietes, so as to be diagnostic. 
I administered tinct. secale cornut. This controlled in some degree the he- 
morrhage but produced no forcible contractions, and she went on in the same 
manner, with a slight but constant flow for six days, constantly taking of the 
above recipe a drachm from every half hour to every four hours, as occasion 
required. 

February 17, 5 A. M., I was sent for on account of somewhat increased 
hemorrhage and pains, and in half an hour a female foetus was delivered en- 
tirely enveloped in the membranes, merely punctured, but unruptured, the 
occiput being immediately under the presenting placenta. No subsequent 
flooding or untoward accident occurred, and on the third or fourth day the 
woman was up, about the room. The specimen was shown by me to Pro- 
fessor Alonzo Clark's class at the College of Physicians and Surgeons of this 
city. 

I wish to say, in this place, that, without the aid of chloroform, I think it 
would have been almost impossible to have effected many of these operations. 
In no case is it of so much importance as in one of neglected arm presenta- 
tion, or any case where turning is necessary, and the uterine contractions 
vigorous. 

New York, 153 Wooster Street t 
March 25, 1852. 



1852.] Brainard, Resection of Superior Maxillary and Malar Bones. 131 , 



Art. XIII. — Case of Resection of the Superior Maxillary and Malar Bones. 
By Daniel Brainard, M. D. ; Prof, of Surgery, etc. 

I was consulted, October 17, 1851, by Caleb Inman, a highly respectable 
citizen of Wisconsin, residing near Belait, about a tumour of the left upper 
jaw. It projected in front below the eye, where there was an ulcerated 
surface ; downward into the mouth, where there was an opening discharging 
pus and serum ; it encroached upon the mastoid, from which there was a dis- 
charge of mucus, and projected outwardly beneath the zyzomatic arch. 

It commenced about eight months previously with a discharge from the 
nostril. Soon after a tumour appeared beneath the eye, which ulcerated or 
was opened; it next encroached upon the mouth, and when the teeth fell out, 
a discharge from the antrum took place. Its growth has been rapid, and 
attended by much pain. 

The patient was sixty years of age, and his health was somewhat im- 
paired. 

The treatment had consisted of applications of nit. silver to the ulcerated 
surface, injections of a solution of it into the antrum, and the iodide of potas- 
sium, in solution, given by the mouth. 

The operation for its removal was performed October 18, 1851, in presence 
of Drs. Butter, M. Arthur, and several other physicians and students. 

The tumour was uncovered by an incision extending from the nose to the 
zygomatic arch, and another from it to the angle of the mouth, and dissecting 
up the flaps. The palate portions of the superior maxillary and palate bones 
were divided by a metacarpal saw, carried into the nostril; the nasal process 
* of the superior maxilla, the connection of the frontal and malar bones, and 

the zygoma were separated by the bone scissors. This loosened the mass, 
which was so much softened that its removal was completed by the knife. 

The hemorrhage was copious, and required ligatures to be placed upon 
numerous enlarged branches of arteries. 

It is scarcely necessary to add that there was great depression resulting 
from the operation. 

The wound having been filled with balls of lint, stitches were applied to 
the flaps, and the patient put under the influence of opium in full dose. 

In aged and debilitated patients always, and in others much depressed by 
formidable operations, I am in the habit of giving immediately and continuing 
not only soups and farinaceous drinks, but saline food and stimulants. 
Chicken broth, which contains two per cent, of animal matter to ninety-eight 
of water, is insufficient ; good porter or brandy and meat are necessary. 

Under the use of this treatment my patient convalesced without a bad 



132 Brainard, Resection of Superior Maxillary and Malar Bones. [July, 

symptom, and in twenty days was able to return home. I have received a 
line from him, dated April 3, 1852, which states that his health is good. 

On examining the tumour it seemed to be composed of a congeries of 
mucous follicles resembling the tonsils, the bony structure being entirely 
destroyed. It presented no trace of cancerous tissue, and no cancer-cells 
were detected by the microscope. 

Chicago, April 27, 1852. 



1852.] 



133 



REVIEWS. 

Art. XIY. — The Principles of Surgery. By James Miller, F. R. S. E., 
F. R. C. S.E., &c. &c. Third American from the second and enlarged 
Edinburgh edition, illustrated by two hundred and forty engravings on 
wood. Revised, with additions, by F. W. Sargent, M.D., member of the 
College of Physicians of Philadelphia, &e. Philadelphia, Blanchard k Lea, 
1852 : 8vo. pp. 751. 

We believe that no single volume on the principles of surgery ever found 
greater favour with the profession than did the first edition of Prof. Miller's 
book. Its style was attractive, and it evidenced a desire on the part of its 
author to win more attention to the science of surgery than was commonly 
bestowed; while it successfully demonstrated that the great body of facts which 
had been constantly accumulating in the course of the practice of the a rt could 
be harmonized and classified under definite laws, with as much propriety and 
advantage as the corresponding materials of any other department of human 
knowledge. It cannot be denied that the petty details of mechanical surgery, 
the multiplying and modifying of operations, particularly, have engrossed a 
disproportionate share of the attention, and obtained a higher place in the 
estimation of surgeons than they deserve, as compared with the investigation 
of the pathological laws which regulate the origin and progress of surgical 
diseases, and the vital reparative actions upon which the success of the sim- 
plest operative proceedings must depend. We do not say that surgery as a 
science has been materially injured by this division of labour, further than 
has accrued in consequence of the erroneous impressions formed as to the 
comparative importance of the principles and the art. For, it is necessary to 
collect facts before laws can be framed; and it generally happens that those 
who are the most attentive to the details, and most fond of the minutiae of 
practice, are the least qualified to group these particulars according to their 
analogies, and to deduce the legitimate scientific conclusions from them. 
Hence the multiplicity of crude and unfounded laws, so called, in medicine 
and surgery. 

Professor Miller, however, has not only the opportunities and the powers 
of observation necessary to the proper collection of facts, but the higher quali- 
fications which enable him to combine and arrange them; and, consequently, 
he has presented us, in the volume now under review, with a most admirable 
digest of the principles of surgery. By describing pretty fully the peculiari- 
ties of the several pathological processes as they manifest themselves in the 
different tissues, he has contrived also to introduce as much of practical sur- 
gery as could be expected in a volume limited in size and confessedly devoted 
to the theory. Many important subjects, on the other hand, are not noticed, 
as wounds of the cavities, hernia, stone in the bladder, diseases of the eye, &c. ; 
but these do not require any mode of treatment so special to themselves, 
excepting in the peculiarity of operative proceedings, as to need separate 
mention. We will endeavour, by quotations and by comments, to present a 
fair exposition of the character and merits of the volume. 

After a comprehensive, though very general, outline of the history of sur- 



134 



Reviews. 



gery, originally contributed by Mr. Miller to the Encyclopedia Britannica, 
the proper subject of the volume is commenced by an account of the " Consti- 
tutional Affections in Surgery," including fevers, cachectic affections, and 
affections of the nervous system ; and the modes in which affections of internal 
organs occur as complications with surgical disease are described. 

The author treats of Scrofula and Tubercular Disease as one, while he vir- 
tually admits that, to a certain extent, at least, some distinction exists between 
them. He says : — 

" The frequent association of scrofula with a peculiar form of morbid product 
has long been observed. This deposit, which will presently be described under 
the name of tubercle, occurs very frequently in enlarged lymphatic glands, lead- 
ing to a slow process of suppuration and ulceration there. It may also affect 
various internal organs, as the lungs, brain, intestinal and mesenteric glands ; 
in which situations it proves the source of various destructive diseases. We 
cannot, however, limit the term scrofula, as some have done, to disorders arising 
from tubercular deposit; inasmuch as most affections of the skin, mucous mem- 
branes, and joints, in scrofulous individuals, have no such origin. Nor, on the 
other hand, can it be admitted that tuberculization of the internal organs, at 
least in adult life, is always, or even generally, a disease of the scrofulous habit. 
All that can be fairly said is, that tubercular disease of the external glands is 
a frequent concomitant of scrofula; as is also a similar affection of the mesen- 
teric glands. And that, in a certain indeterminate number of instances, tuber- 
culization of internal organs follows, or accompanies, the characteristic evidences 
of scrofulous disease ; while, in others, it is quite an independent affection. 
Still, however, as most of the forms of tubercular disease which come under the 
notice of the surgeon are distinctly scrofulous, it is requisite to treat of these 
affections under one head." — p. 63. 

This is, perhaps, the best manner of treating the subject, instead of attempt- 
ing to prove at length the identity or the distinctiveness of the two; for after 
all that has been written on this vexata qusestio, the decision seems to be as 
remote as ever. Indeed, until pathologists can be induced to agree to consider 
as tuberculosis, that complex diseased condition only of which the product 
which we call tubercle is present as the anatomical representative, we know 
not how the unity or diversity of the two cachexise can be determined ; for 
until some such starting-point be adopted, fixed and clearly defined in its 
characters, there must continue to be disputes about terms. It would certainly 
be much more in accordance with the principles which govern us in the diag- 
nosis of other affections, to associate with the symptoms of tubercular disease 
an anatomical lesion which is found to be constant, if such an one can be shown 
to exist. With the exanthemata, we have an eruption peculiar to each; with 
typhoid fever, an especial lesion of the follicles of the mucous membrane of the 
small intestines, &c. ; with carcinoma, a distinctive anatomical structure. And 
however strong may be our conviction, from the symptoms, that we have such 
or such a disease to deal with, if the peculiar physical appearance be wanting 
during life, or if we do not find after death the lesion which we commonly 
associate with the disease, we are compelled to admit that a doubt exists as to 
the correctness of our diagnosis. 

We believe that much of the confusion and conflict of opinion, upon the 
question of the identity of scrofula and tuberculosis, arises from the vagueness 
of our ideas as to what really is scrofula, and from certain assumptions con- 
cerning the morbid product which we ordinarily ascribe to it. The term 
scrofula was originally employed to designate the swellings which were observed 
in the necks of pigs, and, by extension from them, of human beings (see 
Phillips on Scrofula, chap, i.) ; and even to this day these same enlargements 
of the superficial lymphatic glands are considered as most pathognomonic of 



1852.] 



Miller's Principles of Surgery. 



135 



this disease, which is also made the reputed parent of many other chronic and 
very obstinate local affections, of almost all such, in fact, which cannot posi- 
tively be ascribed to some other source. And now, since it has been clearly 
ascertained that the usual termination of these enlarged glands is in suppura- 
tion and ulceration, that the morbid deposit thrown off from them is identical 
with the tuberculous, is, indeed, tubercle, (yid. Lebert, " Des Maladies Scrofu- 
leuses et Tuberculeuses/') and that the ulcers left resemble those which are of 
undoubted tubercular origin ; it is immediately inferred, and with apparent 
propriety, that scrofulosis and tuberculosis are one and the same. 

Now, we ask, would it not be wiser, more in accordance with the spirit of 
exactitude which is gradually working its way into medical reasoning, to con- 
sider, with Lebert, as tuberculosis that form of constitutional disease which 
only and always produces tubercle, whether it exhibits itself in the superfi- 
cial or visceral lymphatic glands, or in internal organs; and to group under 
the head of scrofula those other chronic inflammatory or non-inflammatory 
engorgements of the lymphatic bodies, the local, subacute, or chronic inflam- 
mations implicating chiefly the skin and subcutaneous areolar tissue, the eyes 
and ears, the articulations and the bones, and which, equally without any pecu- 
liar morbid deposition, manifest a tendency to ulcerate and suppurate; or else 
to reject altogether the term scrofula, which conveys such different impressions 
to different minds, and means nothing very definite, and to regard, with Mr. 
Phillips (op. cit. Am. ed., p. 31) — 

" Those diseases called scrofulous, but in which no scrofulous matter is pre- 
sent, as not scrofulous at all, but simply the result of such low inflammatory 
action as is often set up in a debilitated state of the constitution?' 7 

(It must be borne in mind that, in speaking of " scrofulous matter" Mr. 
Phillips refers to that found in the superficial lymphatic glands, which is really 
tubercle.) 

We think it must be admitted that, in many cases of inflammation occur- 
ring in persons of the so-called scrofulous diathesis, a deposit takes place in 
the inflamed part, which is neither tubercle nor analogous to the product of 
healthy inflammation; not yet does it possess physical and chemical properties 
so peculiar and constant as to be deservedly termed scrofulous matter, par 
excellence. This deposit is very frequently removed by absorption, without 
exciting inflammation and suppuration, from the external lymphatic glands, 
and probably also from the lungs (yid. a paper by Dr. Pepper, " on Scrofulous 
Inflammation of the Lungs," Am. Journ. Med. Sci., April, 1852). 

But, to return to Professor Miller. After pointing out the peculiarities of 
the scrofulous cachexia, and the general and local effects induced by it, he 
describes the physical and chemical qualities of tubercle, and illustrates the 
former by some very excellent drawings copied from Dr. Bennett's contribu- 
tions to this subject. He has omitted, however, to trace the changes which 
occur in the tubercular deposit; but this has been done fully in a note by the 
editor. The special pathology of scrofula and tubercle is detailed in the 
second part of the volume, where the diseases of particular tissues are 
described. 

We pass to the chapter on Inflammation. This important and complex 
process is very fully explained ; it occupies nearly one hundred pages. The 
author has evidently studied this subject with very great care, by clinical and 
experimental aids, as well as by reference to the best authorities. Indeed, 
he has accomplished this portion of his task so well, that he has scarcely 
exposed himself to criticism, excepting in some few and comparatively trivia! 
points. 



136 



Reviews. 



We may observe that he does not pursue to any length the purely specu- 
lative portion of the theory of inflammation. And, in questions of this kind, 
whenever he is compelled to express an opinion, it is generally in favour 
of moderate views. Thus, in the section upon the theory of inflammation, p. 
116, he says: — 

"It has often been disputed whether inflammation is caused by increase or 
diminution of vital strength in the part — an excitement or a debility ; and both 
extremes have been tenaciously held and argued. According to the preceding 
account, the fact may be said to lie nearly midway between the disputants; the 
action being found to commence with excitement, and probably with an exaltation 
of the part's vitality; this, however, proving usually of short duration, and suc- 
ceeded by growing debility and much ultimate prostration. True inflammation 
having been established, vital power is sunk very low. And what is worse, 
from this overthrow the part, once truly inflamed, never wholly recovers, but 
ever remains more prone to action, and less able to control it; a fact, which it 
is of much importance that both patient and practitioner should bear in 
remembrance." 

It is very difficult to avoid using forms of expression which have long been 
employed in medical writings and discussions, even though we may no longer 
use them in their original sense. Thus it is with the terms action, action of 
vessels, <fec. The former occurs, as the reader will have noticed, in the above 
quotation, and elsewhere ; yet Mr. Miller does not seem to lay any great stress 
upon the state of the bloodvessels in and about the inflamed part; regarding 
them, as do all enlightened pathologists, merely as carriers of the blood, and 
looking upon the process of inflammation as a modification of that of nutri- 
tion ; and hence, seeking for the explanation of its phenomena primarily in 
some disturbance of the normal relations and reactions between the tissues 
and the blood, rather than in any alteration in the condition of the vessels, or 
in the motion of the blood itself. 

The period of transition from the healthy condition to the actual establish- 
ment of inflammation, is divided by the author into three stages: 1. Simple 
■vascular excitement ; 2, active congestion; 3, true inflammation. This divi- 
sion would have been more accurate, as well as more comprehensive, as it 
seems to us, if the instrumentality of the nervous system in the causation and 
phenomena of the process at its very outset, had been as prominently and 
distinctly acknowledged as the vascular. We would have the first proposition 
to read simple nervous and vascular excitement ; and, indeed, throughout the 
whole process the same nervous agency should be allowed to play an important 
part. For, although in plants local vascular turgescence and increased nutri- 
tion are often excited by local irritation, as is exemplified in the production 
of the galls; and, although in animals inflammation is not unfrequently 
induced in parts paralyzed — proving thereby that the existence and integrity 
of the nervous system is not essential to these processes — there are yet abund- 
ant facts to show that where there is a nervous system, and especially where 
it is most highly developed, it does exert an influence upon normal as well as 
morbid nutrition. What the nature of this influence is — whether it displays 
itself in the reaction which the molecules of the tissues exercise upon the 
blood- plasma, or whether it is primarily wrought upon the bloodvessels — we 
are not yet able to determine. 

And there is another point of view from which the importance of the 
nervous element in the process of inflammation may be contemplated. The 
nervous system constitutes, undoubtedly, the protective element of the animal 
organism. By means of it animals are placed in relationship with the exterior 
world; by it they are informed of the existence of things necessary to their 



1852.] 



Miller's Principles of Surgery. 



137 



being, and are enabled to possess themselves of these ; and by it they are 
made aware of dangers which threaten them, and also have the means of 
avoiding or overcoming them. By it, too, they are made acquainted with 
their own interior condition — their necessities and the derangements to which 
they are continually subject. To suppose that a piece of mechanism so won- 
derful in the perfection of its structural arrangements as the animal organism — 
as man, for example — would not be furnished with powers adequate, within 
a considerable extent, at least, to the protection of itself against the effects of 
disease, and to the reparation of structural injury, would be to sink the power 
and wisdom of the Creator below the level of the same attributes as displayed 
by man in the construction of much of his handiwork. Inflammation is 
oftentimes one of those preservative and protective agencies in the economy; 
it is one of the means by which the system or the part rids itself of various 
agents of mischief, introduced from without or generated within, and from 
which it could not otherwise free itself. In Surgery, examples are common; 
as when a foreign body is lodged in a tissue, and is ejected from it by sup- 
puration ; when the course of mortification is arrested, and the dead part is 
thrown off ; when a malignant or a non-malignant tumour is got rid of by 
sloughing. In the practice of Medicine, the same thing is witnessed in the 
elimination of tubercular and cancerous deposits ; in protective pleurisy and 
peritonitis ; and probably, also, in the rejection of subtle materies morbi by 
the exanthematous fevers. Now in these and similar cases of what may be 
called protective or eliminative inflammation, it must be the nervous element 
of the part implicated which warns of danger or injury, and is primarily the 
active agent in the protective or reparative process. We think, therefore, 
that this element has been too much overlooked by Professor Miller in his 
exposition of the theory of inflammation. 

With regard to the second stage of the morbid process in question, active 
congestion^ we agree with the editor in the opinion that it is made to embrace 
many of the phenomena of actual inflammation ; indeed, the symptoms which 
the author ascribes to it are many of them such as properly belong to the 
early and middle stages of true inflammation, as usually described. He says, 
p. Ill:— 

"The circulation loses its acquired rapidity, and becomes slower even than 
in health. The red corpuscles are no longer limited to the central current, but 
encroach more and more on the lateral and clear ' lymph spaces/ The colour- 
less, or ' lymph globules/ are increased in number ; and by becoming unusu- 
ally adhesive to each other and to the walls of the vessels, are supposed to act 
obstructively — contributing to the slowness of movement in the blood. Exu- 
dation is more copious than in the previous stage, and of a different kind. It 
consists chiefly of liquor sanguinis ; and this is altered from the healthy 
standard. The fibrin is increased, not only in quantity, but also in plasticity, 
or tendency to become organized/ 7 

Consequently, he is obliged to advance considerably towards an actual loss 
of vitality in the part before it can have attained the stage of inflammation 
proper, which he says is — 

"Denoted by more or less extravasation and destruction of texture, and the 
formation of pus in progress. Thus, true inflammation, structurally considered, 
consists of suppuration, actual or imminent, surrounded by fibrinous deposit, 
and that encircled by effusion of serum." — p. 116. 

Upon this point the editor observes : — ■ 

"In many organs, as in the lungs, the heart, the serous and synovial mem- 
branes, undoubted and violent inflammation often exists without the formation 



138 



Reviews. 



of pus at all ; and even upon the exterior, suppuration is not always conse- 
quent upon true inflammation, at least as this process is usually understood.' ; — 
Note to p. 116. 

The symptoms of inflammation; its local and general effects; its duration 
and character; the circumstances which affect it in both of these particulars; 
and its terminations in resolution, in excessive deposits of various kinds, in sup- 
puration, in ulceration and sloughing, are fully and satisfactorily described. 
And we can assure our readers, that the views unfolded by the author upon 
these important points, are in accordance with those which are considered as 
most judicious and enlightened. The chapter, also, on the treatment of in- 
flammation furnishes a complete exposition of all that scientific research and 
clinical experience have agreed upon as most conducive to the successful 
management of the disease. 

Then follow successive chapters on the Healing Process, and the different 
modes in which it is effected; on Acute and Chronic Abscesses, and their varie- 
ties, purulent infiltration, secondary abscess, pyaemia, &c. &c; on the numer- 
ous kinds of Ulcers ; on Mortification ; Hypertrophy, Atrophy, and Absorp- 
tion. These chapters are not meagre delineations of principles alone, but 
they are exceedingly rich both in the results of scientific investigations and 
in practical teachings; in the latter particular they go much more into details 
than do most of the books which are devoted exclusively to the practice of 
surgery. 

The chapter eighth, on Tumours, is worthy of great praise, and we shall 
best exhibit its excellences by making a few extracts from it. 
At p. 284, of the Origin of Tumours, the author says: — 

" Tumour is always the result of perverted growth and nutrition ; and its 
origin, in particular cases, must be owing to some predisposition either of the 
part or of the system. The latter, indeed, is frequently shown very plainly by 
a tendency to the generation of numerous growths of the same kind in one in- 
dividual. Now, any cause which, in a person so predisposed, leads to an inter- 
ruption, even temporarily, of the normal function of growth in a part, must 
necessarily lay the part open to the action of the predisposing causes of tumour. 
Such a perversion of the normal process occurs, when a blow or other injury 
leads to extravasation and inflammatory exudation. Under ordinary circum- 
stances, this exudation merely accomplishes the wonted salutary end in view ; 
namely, restoration of the continuity of texture, which the extravasation had 
broken up ; and, on this end having been attained, redundancy of exudation 
disappears by absorption, and the normal condition of texture is more or less 
completely restored. But, not infrequently, the absorption is incomplete ; a 
redundancy of fibrinous plasma, in process of organization, remains; forma- 
tive action of the bloodvessels continues in an exaggerated, though simple form, 
in the seat of exudation; the plasma is added to, while the surrounding tex- 
tures are undergoing merely the quiet and healthful changes of ordinary nutri- 
tion ; the swelling increases ; and its growth is now distinct and independent 
of the surrounding parts. This we believe to be the most frequent mode in 
which the simple tumour originates ; not from the organization of extravasated 
blood ; and not as a direct result of, or attendant on the ordinary inflammatory 
process ; but this and the extravasation being rather related to it as the excit- 
ing cause. The blow and the extravasation are followed by fibrinous exudation, 
the result of an exaggerated nutrition effected by the inflammatory process, 
with a restorative and salutary object in view; the exudation is redundant, and 
the excess is not wholly absorbed ; continuance of deviation from the normal 
structure induces a continuance of exaggerated nutrition at that part; accumu- 
lation of organizable plasma results ; and commencement of a new growth is 
established. If the morbid local increase of deposit be of a simple fibrinous 
and plastic character, a simple tumour results; but if, from constitutional vice, 
or other causes, it has departed from the ordinary fibrinous character, then the 
resulting tumour equally deviates from similarity to the original texture. " 



1852.] 



Miller's Principles of Surgery. 



139 



The histology of the simple homologous tumours, is analogous to that of the 
normal tissues of the same kind, and their mode of growth presents scarcely 
more difficulties to the student than the development and growth of the natu- 
ral structures of the body ; for their elements are similar and their nutrition 
is effected in the same manner. But the reason why a particular form of 
tumour springs up from one part, and another from another part, or why 
the modification of nutrition should assume the character of tumour at all, 
will perhaps always be a mystery. Much greater difficulty occurs in the case 
of the heteromorphous growths, the peculiar elements of which have no ana- 
logues in the normal structures. Merely to refer them to special constitutional 
vices, rather multiplies than lessens the difficulty, because the origin of the 
parent dyscrasy is equally an enigma. Mr. Simon well observes (Lectures on 
Pathology, p. 152) : " The evolution of a cancerous tumour in the body marks, 
I apprehend, a new state of things in respect of the patient's total organiza- 
tion and vitality; just as much as the first acting of the kidneys in the 
embryo, and of the lungs in the infant, respectively mark new eras in the 
animal's progressive development." And one cannot but agree with him in 
believing that, in order to gain the clue to this labyrinth, we must first ac- 
quire accurate knowledge of the chemical alterations which the blood has 
undergone at the outset of the cancerous disease, by comparison of the total 
chemistry of the cancerous body — blood, tumour, excretions — with the total 
chemistry of the healthy body. 

Professor Miller adopts, as the most practical and useful classification of 
tumours, that which is based upon their malignancy or benignity. But he 
admits that these two great classes pass into each other by very insensible and 
scarcely describable gradations. With respect to the degeneration of be- 
nignant tumours, he contends that this event does happen, and not unfre- 
quently. He says : — 

" Degeneration may proceed from one of two causes ; general or local. "While 
a tumour is yet simple, the constitution may undergo an untoward change, 
cachexy becoming established ; and the tumour will then gradually sustain a 
corresponding alteration. In this manner, a tumour of the breast, originally 
of a non-malignant nature, often insensibly passes from the simple to the car- 
cinomatous structure and tendency; the signs of degeneracy in the system 
preceding those of the evil change in the part. Or, on the other hand, the sys- 
tem yet remaining apparently unchanged, the tumour itself degenerates, in 
consequence of repeated local excitement; as by blow, puncture, or stimulant 
inalapraxis." 

And, again, after speaking of the effect of acute inflammatory action upon 
the condition of the tumour, he says : — 

" The more chronic and minor action is less marked in its operation, but 
equally decided and often more untoward in its effect. At first, it may cause 
mere acceleration of the growth, by increase of the same deposit as before ; the 
tumour enlarges, but is yet of its original simplicity of structure. But, after a 
time, the deposit changes ; the action is altered, too ; and the nutrition is not 
merely exalted, but perverted," &c. — pp. 288-9. 

Degeneracy from the first cause, the inter-occurrence of constitutional ca- 
chexy of the cancerous character, we cannot but admit; for if this dyscrasy 
may occur in an individual whose nutrition has to all appearances been nor- 
mal in kind and degree, much more may it not supervene in one whose nu- 
tritive processes have already manifested a disposition to, nay an actual, aber- 
ration ? and the product of this degeneration will be a heterologous deposit. 
But that a tumour originally simple in its character, can by mere local irrita- 
tion, without the prior induction of the constitutional cachexia, become malig- 



140 



Reviews. 



[July, 



nant, we are not prepared to believe; this doctrine removes from the class of 
cancerous tumours the property upon which their distinctiveness is mainly 
based ; namely, their dependence upon a peculiar alteration of the constitu- 
tion for their production, which Professor Miller himself admits. 

After discussing various other matters connected with their general patho- 
logy, the author proceeds with the consideration of special tumours. Those 
which are particularly described are the simple tumour, or simple sarcoma; 
fibro-plastic tumours; the true fibrous; the fibro-cellular ; the fatty; the 
cystic; the cartilaginous; the calcareous; the scrofulous, and the varieties of 
the malignant tumours ; the vascular and the osseous are described in connec- 
tion with diseases of the vascular system, and the bones respectively. The 
tumours of each class receive careful attention, in every important particular; 
and beautifully executed drawings illustrating their appearance in situ, as well 
as in section under the microscope, accompany the explanations of the text. 
The account given of them embraces the sum of what has been unfolded by 
the investigations of the ablest pathological inquirers in Great Britain and on 
the continent, down to the time of the publication of the volume. 

From the judicious remarks of Professor Miller concerning the treatment 
of tumours, we will quote what he says with reference to exploratory punc- 
ture, where doubt exists as to the character of a case under examination. 

" Such exploration is by no means so light a matter as some would seem to 
consider it. It is not warrantable to plunge a trocar into every and any tumour, 
of whose nature there may be some doubt. If it be an abscess, no harm en- 
sues ; the puncture is immediately enlarged for the purpose of due evacuation. 
If it prove to be a solid growth, there may still be no harm ; provided patient 
and surgeon are prepared at once, or at all events, within a day or two, to pro- 
ceed to extirpation. But much injury will not fail to result, if, after puncture, 
the tumour be left to itself for some considerable time ; and, more especially, if 
absurd attempts be made by stimulation to effect its removal by absorption. 
There is no more sure exciting cause of a tumour's degeneration, than the 
thrust of an exploratory trocar. On a section being made of the mass, after 
removal, the origin of the doubly depraved structure may not unfrequently be 
seen in the instrument's track. While, therefore, exploration is expedient, to 
guard against errors of diagnosis which might otherwise occur, and which 
might lead to serious error in practice, its use ought to be limited to very doubt- 
ful cases, in which other means of diagnosis, patiently and skilfully used, have 
failed to satisfy; and not even in such cases should it be had recourse to, un- 
less early operation, if not immediate, have been determined on, in the event 
of the swelling being proved to be an undoubted and indiscussible tumour. ;; — 
p. 328. 

The succeeding chapter, on Hemorrhage, embraces a very good account of 
all the varieties of this accident; the predisposing and exciting causes upon 
which each depends, their effects upon the system, and the natural and arti- 
ficial hemostatic agents. Many of the accompanying drawings are new and 
very expressive. 

With this chapter closes the first section of the volume, devoted, as we 
have seen it to be, to an account of the general or constitutional surgical 
affections. The second section describes the diseases of Particular Tissues, and 
their treatment. 

Among the diseases of the Integument are enumerated erythema, erysipelas 
in its numerous phases, hospital gangrene, furunculus, carbuncle, diffuse in- 
flammation of the areolar tissue, cntozoa and tumours of the integument. 

In the treatment of Erysipelas, of the simple variety, which " is from the 
first acute, and obviously progressive, local bloodletting is advisable," the 
author says. He objects to leeches ; as being apt to stimulate the surface by 



1852.] 



Miller's Principles of Surgery. 



141 



their bites and suction ; he prefers punctures, rapidly made with the point of 
a lancet. 

" This practice," he continues, "may startle those who are practically unac- 
quainted with it, by its apparent severity. But the severity is only ideal. We 
grant that, in one point, the infliction of temporary pain, it may be more severe 
than leeching ; but in every other it is much and truly superior. Alarming it 
may be to the timid patient ; but it is quickly over. A few seconds suffice ; and 
the relief is both satisfactory and instant. In the more severe cases, which 
demand its use, the pain of infliction is often the least. The acute pain, already 
existing in* the part, masks that of the punctures ; in the same way as the ope- 
ration of scarifying tense and painful gums seems, not unfrequently, to be 
agreeable rather than otherwise to the teething child. And, as already stated, 
the ultimate cicatrix of each puncture is so trifling, as to render the practice 
equally applicable to the face, when erysipelatous, as to any other part of the 
surface." — p. 369. 

After a careful and minute description of each variety of the disease, he 
gives the following general characters of erysipelas, p. 377: — 

" Tendency to spread ; tendency to change its site by metastasis ; tendency 
to prevail in an epidemic form ; deficiency of concomitant fibrinous and plastic 
exudation ; rapid attainment of the suppurative crisis. The pus, as if imper- 
fectly concocted, thin, and non-laudable ; by its diffusion, danger to texture 
great. In the constitutional symptoms, the inflammatory type seldom pre- 
dominant ; tendency to the asthenic character usually strong, often even from 
the first; gastric and biliary disorder, with general derangement of secretion, 
primary and great. Active local treatment not advisable, when texture is not 
in danger ; but when diffused suppuration is threatened or established, free 
incision alone remedial. Active constitutional antiphlogistics in few cases well 
borne ; unnecessary, except in the most sthenic and intense examples ; and, 
even then, to be employed with much prudence and moderation. In the ma- 
jority of cases, and comparatively early in all, constitutional support, on the 
contrary, demanded. In short, an asthenia, or tendency thereto, reigns through- 
out. And by some this is accounted for, by supposing a poisonous influence to 
be exerted on the system ; either generated within, during or by the inflam- 
matory process: or conveyed from without, by atmospheric influence, or by 
direct contagion." 

The chapter on the affections of the Serous and Mucous Membranes includes 
inflammation of both, and Polypi. 

The next subjects treated of are affections of the Periosteum and Bone, in a 
lengthy chapter of seventy pages, embellished by very many excellent draw- 
ings. That portion of it which is occupied with the consideration of inflam- 
mation of bone, and its various results in change of structure ; in the formation 
of pus upon the surface, or in the interior, either diffused or limited, acute or 
chronic, simple or scrofulous; in ulceration, simple or carious; and in necro- 
sis, will amply repay a careful study. The different forms of morbid 
growths, occurring in and upon the bones, receive also their full share of 
consideration, not only as to their pathological nature, but likewise with 
reference to their diagnosis and treatment. 

As an instance of the author's constant endeavour to apply sound prin- 
ciples to the treatment of local diseases, we present the following extract from 
his remarks on the treatment of periostitis. The suggestion bears upon a 
condition which is by no means uncommon, and which it is very important to 
relieve : — 

" Sometimes action seems to be partially arrested, yet does not decline ; a 
tense and painful swelling remains unabated; and, on the contrary, tending 
still to increase. It is plain that relief of tension would be a most important 
No. XL VII. — July, 1852. 10 



142 



Reviews. 



indication under such circumstances. For a similar state of matters, uncon- 
nected with bone, we would freely practice incision ; tension would be at once 
relieved, and action would speedily decline ; the woujid would suppurate, and 
its margins would perhaps slough, but granulation and closure would speedily 
follow. Here, however, similar procedure would be rash and untoward. Ten- 
sion would doubtless be relieved; but with suppuration, which is inevitable, 
would certainly come either ulceration or death of the bone ; the very results 
which we seek to avoid. Direct incision, therefore, is plainly unwarrantable. 
But, by inserting a fine bistoury, or tenotomy needle, at a little distance from 
the tense part; passing it over, cautiously, beneath the integument^ then turn- 
ing and pressing its edge so as to divide the tense membrane wholly to the 
desired extent; cautiously withdrawing the instrument, so as to make a valvular, 
oblique, and subintegumental wound ; and, finally, closing the single integu- 
mental puncture immediately, with isinglass-plaster, or collodion — in fact, by 
completing the wound so as effectually to prevent introduction of atmospheric 
influence, and thereby obviating the chief risk of suppuration — we may obtain 
diffusion of the swelling, relieve tension, and so facilitate both resolution of the 
action and discussion of its results. This manoeuvre, however, requires skill 
and caution in its performance ; and even with these, is not wholly devoid of 
risk. It is, therefore, not to be indiscriminately employed, but should be re- 
served for those cases which otherwise prove obstinate, and in which aggrava- 
tion and suppuration seem imminent." — p. 397. 

Next in order follows an excellent chapter on Diseases of the Joints. It is 
based on the most recent and most accurate investigations upon the normal 
and pathological anatomy of the tissues concerned; and is illustrated, as are 
all the chapters in the book, with admirable drawings. We know of no 
formal treatise in which so good a history is given of the changes of structure 
which disease induces in the articular cartilages. The paper of Dr. Redfern, 
of Aberdeen, is used as the starting-point, and much light has been shed 
thereby on the subject. The examinations made by Dr. Redfern have con- 
firmed the account given by Mr. Groodsir, as to the process of cell-modifications 
in diseased cartilage, and the multiplication of nuclei ; and, likewise, as to the 
formation of a false membrane at those points where the cartilage has been 
removed, and even between the cartilage and the subjacent bony surface. 
This false membrane becomes vascular by extension of vessels from the bone 
and synovial membrane; and hence, probably, has resulted the belief that the 
cartilage itself becomes pervaded by vessels, in inflammation. Dr. Redfern 
has also devoted much attention to the alterations which the intercellular 
substance of the cartilage undergoes. He describes this as being in the 
normal state homogeneous and structureless ; but in the process of disease it 
becomes — 

" Split up into bands and fibres ; these are often formed in partially and 
slightly diseased joints, giving a soft and velvety aspect to the surface of the 
cartilage/ 7 — p. 478. 

It will be remembered, doubtless, that Dr. Leidy described, in the American 
Journal, April 1849, the intercellular hyaline substance of cartilage as exhi- 
biting a minutely fibrous structure in the normal state, and the cells as sub- 
ject to increase by division. Thus, as Professor Miller remarks, the analogy 
between the normal and morbid phenomena is apparent. Dr. Leidy has re- 
peatedly confirmed his original observations, so that the matter is no longer 
to be doubted. We have here, consequently, a beautiful illustration of the 
knowledge derivable with reference to pathological processes, from the inti- 
mate research into the normal. 

There are numerous sections of this chapter, from which we might advan- 
tageously quote the author's observations; but we must restrict ourselves in 



1852.] 



Miller's Principles of Surgery. 



143 



this respect. We will select some passages from his remarks upon Loose 
Bodies in Joints. Of their mode of formation, he says: — 

"It is probable that in various ways these substances may be produced. L 
By external growth. A fibrinous deposit takes place exterior to the synovial 
membrane ; and, as it enlarges, that membrane is pushed before, forming a close 
envelop. The little mass projects into the cavity of the joint, and is not un- 
likely to assume a pedunculated character. On a sudden movement, the pedun- 
cle maybe severed ; and the extraneous substance is thrown loose into the joint. 
2. By internal formation, in the substance of the synovial membrane. A fibrin- 
ous mass may form in that tissue, analogous to the adventitious structures 
found in the ' fimbriated' condition of the synovial apparatus, formerly de- 
scribed (p. 473) ; but differing from such formations in being single, instead of 
gregarious ; and ultimately becoming much more dense in structure. It is not 
difficult to imagine how such a formation, at first attached, may become sepa- 
rate, and float loosely within the cavity. 3. By epithelial growth within the 
joint's cavity ; epithelial cells accumulating there, cohering, and growing by 
abstraction of nutritive material from the synovial fluid. 4. By hypertrophy 
of original cartilage. Joints, especially those of the elbow and knee, are not 
unfrequently found in museums, with marked and irregular enlargement of 
their cartilage, and also of the subjacent bone, at the outer rim of the cartila- 
ginous surface. Part of these excrescences may point towards the joint, show- 
ing more or less of the pedunculated form ; and portions may be found within 
the joint, some quite loose, and others yet adherent. Such preparations sufficiently 
indicate the abnormal process whereby this mode of formation may be effected. 
It should also be observed, however, that such hypertrophy is not mere enlarge- 
ment of the original cartilage. The texture is changed, becoming infinitely 
more dense and fibrous ; and it is a portion of this altered tissue which is pro- 
jected and detached." — pp. 495, 496. 

And we will also transcribe the resume of the author's description of the 
operation which he advises for the removal of the body; partly on account 
of the excellence of the operation, and partly to convince those of our more 
practical readers, who may think that a book on the Principles of Surgery is 
not adapted to their tastes, that science nowhere exhibits itself to greater ad- 
vantage than when applied to the art of surgery. 

" The operation, as we would advise it, is thus seen to consist of distinct 
parts. 1. The prophylactic preparation, occupying not less than several daj^s. 
2. The oblique valvular puncture; carefully avoiding the entrance of atmo- 
spheric air even into the superficial areolar tissue. 3. Extrusion of the loose 
body into the areolar tissue, in a different route from that of the puncture ; 
and lodgment of it, subcutaneously, at a safe distance from the synovial 
wound. The second and third parts of the procedure are accomplished at once, 
in immediate succession ; and then two or three days, not more, are allowed to 
elapse, with a view to consolidation of the wounds. 4. By a direct incision, 
the offending substance is finally removed from its temporary abode. It is not 
at once taken away through the original puncture, because it would be in most 
cases very difficult to accomplish this without the admission of atmospheric in- 
fluence; the almost certain consequence of which would be synovial inflamma- 
tion of an intense kind, ending in suppuration and loss of the joint. And, as 
experience has proved, it were alike unsafe to leave it unremoved from its se- 
condary and subcutaneous abode; it being extremely probable that an effort 
would be made by nature to dislodge it thence, by the ordinary means of in- 
flammation and suppuration of the textures around. And then we should, pro- 
bably, be unable to prevent involvement of the synovial membrane." — pp. 497, 
498. 

Several other modes of relief are also described. After enumerating and de- 
fining the various forms of Anchylosis, the author states, in speaking of the 
treatment, p. 504 : — 



144 



Reviews. 



[July, 



" In all cases, anchylosis should be warily interfered with. It is an imper- 
fect cure ; yet both a saving of the part, and a cessation of morbid action. 
And it maybe regarded as a compromise between health and disease ; the rash 
infringement of which is most likely to be visited by untoward consequences. 
The true form is plainly not to be broken up, either by gentle or by violent 
means. The latter have been made trial of, with a result truly deplorable. A 
certain M. Louvrier invented an apparatus, by the rude force of which, stiff 
joints were instantaneously straightened; and patients were submitted to the 
torture of this ' infernal machine/ A few escaped with comparative impu- 
nity, yet with little improvement in the part ; in others, laceration, suppuration, 
gangrene, delirium, were the results; 'accidents frightfully severe, and ordi- 
narily followed by death/ The only means of treatment to which true anchy- 
losis is amenable, is that formerly noticed, by section exterior to the obliterated 
joint, and formation of a false joint thereby ; an operation which has been suc- 
cessfully applied to the hip and knee-joints, but in regard to the expediency of 
which we desiderate a larger experience/ 7 

In connection with this paragraph, is a note by the editor, enumerating all 
the cases of anchylosis of the hip and knee-joints in which Dr. Barton's ope- 
ration has been performed, twelve in number. In one instance only did the 
Datientdie, although two of them were certainly very unpromising subjects for 
the operation. Hence, it cannot but be regarded, for patients favourably cir- 
cumstanced, as an admissible and hopeful operation, so far as experience in- 
forms us. But, as the editor remarks: — 

"The operation is by no means free from danger. In fact, it establishes a 
sort of compound fracture of the femur, and is liable, as was exemplified by 
several of the cases quoted, though undoubtedly in a less degree, to all the 
hazards which attend this injury ; hazards from long and profuse suppuration, 
phlebitis, &c. It is consequently a very important and most responsible posi- 
tion which the surgeon assumes in suggesting and recommending it to his pa- 
tient," &c. 

The fourteenth chapter is upon Diseases of the Arteries. Of course, by far 
the larger part of it is occupied in considering the pathology and treatment of 
Aneurism. The account given of this most important affection is exceedingly 
well conceived in all its parts, and is illustrated throughout by happily se- 
lected drawings. It embraces a minute exposition of the effects of ligature on 
arteries, derived mainly from the researches of Mr. Spence, a portion of which 
was published in 1843, in the London and Edinburgh Monthly Journal; the 
remainder has not yet been made public, but Professor Miller has had access 
to the whole, and has been courteously allowed by Mr. Spence to copy such 
of the drawings as he wished for the present treatise. 

The observations of Mr. Spence have demonstrated the highly important 
and even essential character of the fibrinous exudation which takes place ex- 
ternal to the canal of the artery, besides a similar effusion internally. 

" He has shown clearly that the internal clot, so far from being, as was sup- 
posed by Manec and others, essential to the separation of the ligature without 
hemorrhage, is not unfrequently wanting, when the vessel has been success- 
fully tied ; the closure being entirely effected in these cases by the plastic exu- 
dation between the cut edges of the internal coats, and by the bulky fibrinous 
mass which forms within and around the sheath. It is this external exudation 
which, becoming vascularized, forms the medium whereby blood is supplied 
from all the surrounding parts to the important new formations within the ex- 
ternal coat of the occluded vessel; and which, by its equable pressure upon the 
divided ends of the internal coats, prevents the tender adhesions within the 
sheath from being broken up, even when there is no coagulum. And hence 
arises an important practical caution ; that it is not only advisable, in ligature 
of an artery, to avoid unnecessary separation of the vessel from its sheath, but 



1852.] 



Miller's Principles of Surgery. 



145 



also that every undue interference with the soft parts around is also greatly to 
"be deprecated. According to Mr. Spence, the vessels of the new plastic lymph 
are formed with great rapidity. In one instance, in the dog, he found them 
present, in considerable numbers, sixty hours after the operation. After a 
longer time, vessels begin to pass even into the clot, when this is present ; these 
vessels being always in connection with those of the sheath and external lymph, 
and not proceeding, as has been supposed, from the interior of the artery." — pp. 
537, 538. 

Yery particular attention is devoted by the author to the treatment of 
aneurism • all the numerous methods are described, and a very fair apprecia- 
tion is given of their respective and comparative merits. And when so much 
opposition has been and still continues to be made, out of Dublin, and espe- 
cially, perhaps, in Edinburgh, to the treatment by pressure, without incision, 
it is very gratifying to find that the latter city is so ably represented in 
favour of this plan, by Professor Miller. After a pretty full statement of the 
advantages of, and the objections against, this mode of treatment, he says, in 
conclusion : — 

" That pressure is to supersede ligature altogether, in the treatment of aneu- 
rism, no one can imagine. Some patients, by idiosyncrasy, may be intolerant 
even of such modified pressure as is required; and to some aneurisms the ap- 
plication of it is impracticable. There seems every reason to anticipate that 
the result of experience will determine, that some aneurisms are unsuited either 
for deligation or pressure ; absolutely incurable, by reason of extreme arterial 
degeneration. And that, of the curable cases, some are suited for deligation, 
others for pressure ; just as, in stone, patients are not indiscriminately sub- 
jected to lithotomy, as in former years ; but, while some are cut, others have the 
calculus removed by lithotripsy ; neither operation being exclusively followed 
in the .practice of any wise and thoroughly accomplished surgeon. And fur- 
ther, it will no doubt appear that there are certain cases of aneurism, in which 
it were both unwise and unwarrantable to operate by the knife, when expe- 
rience has shown that pressure will suffice; just as we should be culpable in 
removing a stone by wound of the bladder, which experience tells us may be 
safely crushed, or removed by the urethra entire." — p. 549. 

Affections of the Veins, and of the Lymphatics, are considered in the fifteenth 
and sixteenth chapters respectively; and in the seventeenth, affections of the 
Nerves, including neuritis, neuralgia, and tumours of nerves. 

Neuroma is described as— 

"A simple tumour, and, like the painful tubercle, of the nature of fibro- 
cartilage ; consisting of dense plastic matter lodged amongst the fibrils of the 
nervous tissue, which are thereby separated, and usually rendered the seat of 
perverted sensation. Sometimes the formation occurs spontaneously ; more 
frequently, it follows remotely on wounds, or other external injury," &c. 

Several exquisite wood engravings exhibit the appearance and minute struc- 
ture of these bodies. 

The painful subcutaneous tubercle resembles neuroma in structure, according 
to the author ; though Mr. Paget has always found them to consist of fibrous 
tissue, without cartilaginous admixture. (Paget' s Lectures on Tumours.) 

The eighteenth chapter treats of Wounds of all kinds, their peculiar cha- 
racters, and the treatment best adapted to each variety. Mr. Miller herein 
exhibits himself as an accomplished practitioner, no less than one thoroughly 
versed in the principles of the science ; and this chapter, taken in connection 
with the third, " on the healing process," forms a most admirable study on 
this most common of all the ills to which the surgeon has to minister. The 
most important complications associated with wounds, viz., Hydrophobia and 
Tetanus, are also fully described. 



146 



Reviews. 



The remaining chapters of the volume, on burns and scalds; the effects of 
cold; fracture; dislocation; sprain, and rupture of muscle and tendon; bruise; 
and suspended animation, though very excellent in themselves, contain no- 
thing which demands of us especial comment; to say that they are in harmony, 
so far as their value is concerned, with the rest of the book, is all that is 
necessary. 

The volume concludes with a eulogy on Chloroform — u Him first, Him last, 
Him midmost." It was originally published as introductory to the author's 
course of lectures, in 1848. At that time, very few unfortunate results had 
followed its employment as an anaesthetic agent in surgery ; now, however, 
such instances have become, unhappily, so numerous as to have induced a 
salutary caution with regard to its use, at least in this country ; so that our 
readers will require no reminder from us to the effect that this " Currus 
triuniphalis," not " Antimonii," but Chloroformi, should be ascended with 
some reserve, and driven with more anxiety. 

We may be expected, according to the laws of formal criticism, to pass our 
opinion upon the literary merits of Professor Miller's book. It is a very 
favourable one. His style is animated and agreeable. We cannot say that 
it is invariably correct or elegant ; the definite article is very commonly 
omitted where both of these attributes require its presence. And as " the 
lavish and indiscriminate introduction of commas" was animadverted upon in 
a recent number of one of our most valuable British contemporary medical 
journals, so may Professor Miller, we think, be justly amenable to the charge 
of lavishly and indiscriminately employing semicolons, where simple commas 
would have been more grammatically proper. 

We must not conclude this notice without adverting to the taste and good 
judgment displayed by the editor in the performance of his task. He has 
equally avoided the error of overloading the text with unimportant annota- 
tions and of slighting his duties. His additions are all useful, and comprise 
whatever new facts have been contributed, or important views have been pro- 
mulgated, since the publication of the original work. His principal contribu- 
tions will be found in foot-notes in the chapters on Inflammation, Suppuration, 
Tubercles, Cancer, Tumours, Aneurisms, and Anchylosis. 

Concerning " the getting up," if we may be allowed to use so mechanical a 
phrase, of the American edition of this book, we cannot speak too commenda- 
torily. It is a very jewel of its kind; the paper, the printing, and, above all, 
the wood-cuts, are as excellent as we could desire, and reflect the highest 
credit upon all who have been instrumental in the publication. We do most 
sincerely hope that the publishers will be amply encouraged, by the ready 
sale which this volume finds, to issue all their works in the same style. How 
infinitely more agreeable it is to read such a book as this, than those which 
we are commonly obliged to use ! 

Our pleasant task is now finished, and we take leave of our author and of 
our readers, assuring them that we know of no volume on the principles of 
surgery which can compare with Professor Miller's, in the scientific character 
of the doctrines which it enunciates, and the happy manner in which they are 
applied to the practical duties of the surgeon. 



1852.] 



Births, Marriages, and Deaths in Massachusetts. 



147 



Art. XV. — Report of the Births, Marriages, and Deaths of Massachusetts, 
for the year 1850. 

Eight Reports of the Births, Marriages, and Deaths of Massachusetts, for the 

eight years and eight months, from May 1, 1841, to December 31, 1849. 
Two Reports of the Births, Marriages, and Deaths of the State of New Yorh, 

for the years 1847 and 1848. 
A Memorial to the Legislature of Louisiana, for the Registration of Births, 

Marriages, and Deaths, on behalf of the Louisiana State Medical Society. 

By J. C. Simonds, M. D. 

Every contribution to vital statistics is a gift to humanity. Every fact 
or collection of facts of this nature aids, in its degree, in the elucidation of 
that great subject, the value of human life, and the circumstances and causes 
that impair or increase it. We are thankful, therefore; for the new and ninth 
annual report of the births, marriages, and deaths of Massachusetts, which 
shows the number of, and many of the circumstances and conditions connected 
with, those facts as they took place in that commonwealth during the year 
1850. 

There are now nine of these reports from Massachusetts before the public. 
They cover a period of nine years and eight months, from May 1, 1841, to 
December 31, 1850. And we have the promise of another, the tenth, for 
1851, as soon as the returns from the several cities and towns can be con- 
densed and digested into due form in the office of the Secretary of State. 
The people and the government of that State having entered upon this path 
of vital registration, and persevered so long in its course, with improving 
efforts and results, there is no reason to apprehend any faltering or failure. 
We may, therefore, confidently look for these annuals in future years. 

This system of registration, as applied to States, is almost new in this coun- 
try. It has been in operation for some years in some of the European nations. 
It was first established in England and Wales in July, 1837. The govern- 
ment then and since caused the births, marriages, and deaths to be registered 
in all the parishes and districts of the kingdom, and the whole is annually 
gathered and condensed and published in a large octavo volume. 

The English reports are of great value; besides the registry of the great 
facts of life, they contain the localities, dates, and circumstances of these 
events; the causes of death; dissertations upon sanitary subjects, the preva- 
lence and the severity of various diseases, the value of life in various condi- 
tions, and upon life insurance. Hence these volumes of English mortality 
have a value beyond the mere history of the facts which they record. 

In America, we have hardly made an approach to the fulness and com- 
pleteness of the English system. Our reports consist mainly of the three 
great facts of life — birth, marriage, anal* death. With the exception of a 
valuable letter of Mr. Shattuck in the fourth report, and some excellent obser- 
vations of Dr. Curtis in the eighth report, there are no dissertations on life 
and death, the conditions that affect the force of mortality, or upon the pro- 
gress of population, in any of the series of the reports of Massachusetts. 

The reports of the State of New York, although valuable in themselves 
and useful as far as they go, are still more meagre than those of. Massachusetts. 
They were published for only two years, 1847 and 1848. Since then, they 
have been discontinued. This is a matter deeply to be regretted, for there 
was much to be hoped from these sanitary and mortuary registers of the great 



148 



Reviews. 



State of New York, and from the influence of her example upon other States. 
It was a natural and a reasonable expectation, that New York would give to 
the world as much light upon these matters, from the record of her own ex- 
perience, as she has upon education, crime, agriculture, and natural history, 
in her large and instructive reports upon these subjects. 

In Pennsylvania, the movement has already been begun. A law requiring 
the registration of births, marriages, and deaths has been enacted, which, al- 
though it falls short of what is desirable, yet is a very satisfactory beginning, 
and we trust a foretaste of much that is to come. 

The Louisiana State Medical Society, and the Physico-Medical Society of 
New Orleans have petitioned the Legislature of that State to establish a sys- 
tem of registration of births, marriages, and deaths in Louisiana. The me- 
morial was prepared by Dr. J. C. Simonds, of New Orleans, an able and 
earnest advocate of this measure, and from the clearness of the argument, and 
the satisfactory nature of the reasons set forth, we believe the petition will be 
granted. 

In some other States, the friends of this system are striving to awaken pub- 
lic attention to it, in the hope of ultimately procuring its adoption by their 
several legislatures. 

Several cities have made and published their records of these great events 
of life in various degrees of fulness Some have given merely the numbers 
of those who were born, and married, and died. Some others have added 
the dates of all these events, the causes of death, the ages and sexes of the 
deceased, and other particulars of great value. We have these annual reports 
from New Orleans, Charleston, Washington, Baltimore, Philadelphia, New 
York, Providence, Boston, and Lowell. They differ widely in their character 
and completeness, and most of them grow better and more satisfactory with 
increasing experience. The annual reports of Philadelphia, always meagre, 
have not latterly been regularly published since the year 1846. Those for 
the years 1847, 1848, and 1849 have been issued only within a few weeks, 
and we are still without those for 1850 and 1851. 

Our present purpose is not to notice the reports of these cities, but to ana- 
lyze those of Massachusetts and the State of New York. 

The earlier reports of Massachusetts and those of New York are very in- 
complete. This was expected. It was so in England. It requires the co- 
operation of a great many officers, and of almost all the people, to produce 
full and correct returns. No central office, however well organized or power- 
ful, no officers, however intelligent and efficient, can collect the births, mar- 
riages, and deaths alone, from any State or nation. There must be numerous 
agents or officers distributed for this purpose in all the districts and localities. 
Besides this, they must receive the active aid of some member of, or some 
person familiar with, every family in which-either of these events takes place. 

It is not to be supposed, that the whole people will, at once, and imme- 
diately after the enactment of any registration law, yield to it full and active 
obedience. We consequently find, in the earlier reports of England and Mas- 
sachusetts, and in those of New York, from the officers that have charge of 
them, complaints of the entire neglect of many towns, and of the manifestly 
imperfect returns of some others. 

In Massachusetts, there were thirty-five towns out of three hundred and 
five in the State, containing 76,654 inhabitants, that made no returns in 1842, 
the first year that they were required. Eight other towns, containing 18,183 
inhabitants, made no return of deaths. Twenty-six towns, containing 83,092 
inhabitants, returned no births. Three of the smallest towns in the State, 
with a total population of only 951, reported no marriages in that year. 



1852.] 



Births, Marriages, and Deaths in Massachusetts. 



149 



The returns from many other towns were evidently incomplete. The clerks 
of some of them seemed to have returned to the Secretary of State only such 
of these facts as happened by accident or otherwise, to come to their know- 
ledge. They had taken no pains to obtain them, and had put in operation 
no active inquiry. 

The consequence was, that there were returned in that year, 1842, and 
published in the first report, only 8741 births, 5742 marriages, and 9544 
deaths, in a population of 737,326. 

In the next year, only thirteen towns failed entirely of this duty; all the 
rest reported an increase of births, marriages, and deaths. From that time, 
there has been a gradually increasing attention to the requirements of the 
law until 1850, when reports were received from every city and every town 
in the State but eight, which contained 19,087 inhabitants. The returns 
last received bear evidence of much more accuracy and completeness ; and 
probably most of them contain all of those events that occurred in the cities 
and towns. This ninth report stated that there were 27,664 births, 10,345 
marriages, and 16,606 deaths, among 975,578 people in 1850. 

The two reports from New York bear the same evidence of incompleteness. 
The Secretary of State says, in his first report, that he had received returns 
from the clerks of all the counties but Washington. But there were one 
hundred and ninety-nine towns that made no returns to the county clerks. 
Only one city, New York, made these returns. Some other towns reported 
only the marriages, some only the births, and some only the deaths, and some 
others reported two of these classes of facts. A considerable proportion of 
those which were received, plainly included only a part of the facts. Copake, 
with 1607 inhabitants, in 1840, reported 3 marriages and 56 births in 1847. 
Ephratah, with 2085 inhabitants, reported 3 marriages and 73 births. Scipio 
reported 3 deaths in 2136 inhabitants. Chester reported 8 births, 5 mar- 
riages, and 4 deaths among 1744 people. New Windsor reported 20 births, 
1 marriage, and 12 deaths, in a population of 2474. 

This first report stated that there were 35,897 births, 11,437 marriages, 
and 17,263 deaths, in the year 1847, in the towns and cities which had made 
returns. 

The second report, that for 1848, showed a little improvement. Returns 
were received from all the counties but Clinton and New York. Two hun- 
dred and twenty-five towns and seven cities failed to make returns. The 
others reported 33,621 births, 11,582 marriages, and 18,578 deaths. 

Here was a deficiency of twenty-six towns and seven cities, including New 
York, which had made returns in the previous year. Here was also a de- 
crease of report of 2275 births, but an increase of 155 marriages and 1315 
deaths. As the decrease of reported births was in a smaller ratio than the 
decrease of reporting towns, and as there was an increased report of the other 
parts, it is reasonable to suppose that there was a greater fulness and accuracy 
in those returns that were made, and that the tables showed more truly the 
ratio of births, marriages, and deaths, to the living, in 1848, than in 1847. 
There might have been some special reasons for the entire neglect of the 
failing cities and towns. But it is apparent, that the officers of the other 
cities and towns made more effort to obtain all the facts, and return them to 
the Secretary of State. 

These are all the reports that have yet been made by the State of New 
York. What progress or improvement will be made in the succeeding reports, 
if they ever appear, is yet to be seen. 

These eleven reports of Massachusetts and New York are all that have yet 



150 



Review* 



[July, 



been made to the public by any State or national authority in respect to the 
great facts of life and mortality in America. 

The English registration system met with similar imperfect success in its 
early years, and fell short of the ideals which the law had marked out. But 
as in Massachusetts the returns became more and more complete, until now 
they seem to contain all the facts required. The first report for 1837-8 in- 
cluded 399,712 births, 111,481 marriages, and 335,956 deaths. The fifth 
report included 512,158 births, 122,496 marriages, and 343,847 deaths. 
The twelfth report included 578,159 births, 141,833 marriages, and 440,853 
deaths in 1849. 

This progress from deficiency and incompleteness to fulness and complete- 
ness is what must be expected here and everywhere. All systems of this 
nature must pass through the same probation of ill success and improve- 
ment before they can gather and give to the world such a complete set 
of facts as may be received as the basis of all desirable calculations upon 
population and mortality, and especially such as will afford unquestionable 
ground for comparison of one State or nation with another in respect to these 
matters. 

This imperfectness in these reports is frequently used as a charge against 
them, and a valid objection to the whole system of registration. On this 
ground the opponents of such a law resist it before it is established, and its 
enemies find reasons therein to attempt its overthrow after it has begun its 
operations. Without doubt, the friends of the system sometimes claim too 
much for it. They present their few facts in such a way, and draw such in- 
ferences from them as are not justified by statistical science. 

It would be unphilosophical to compare the rate of mortality of New York 
and Z>Iassachusetts or England on the basis of the reports we have of the for- 
mer State or of the earlier reports of the latter. The average number of 
deaths in New York in the reported years, compared with the population of 
the whole State, gives a mortality of 1 in 145 inhabitants. Or, if we com- 
pare the deaths with the population of the towns reported, we must still 
include many such towns as Summit, which reports a mortality of 1 in 393, 
and Waterloo, whose mortality is reported to be only 1 in 726 of the living, 
and others of a higher ratio, but still falling short of the probable facts. 

A similar difficulty would be found in the early reports of Massachusetts, 
which in the first two years reported a rate of mortality of 1 in 72 of the 
living in the whole State. If we omit the towns that made no report, we 
must still include such towns as Seekonk, which returned 1 death in 1996, 
and Attleboro, which reported 1 in 3585 of its people. The rate of mortality 
should not be attempted to be deduced from these returns until the system 
shall be so completely established as to insure the report of all the deaths 
among any definite number of people. 

There are other facts of great value that may be established by this system 
of registration, although the returns may be incomplete as to number. 

It is important as a matter of political economy to have such public and 
permanent records concerning every individual, that he may be able to esta- 
blish his identity, his personality, and his relation to others; and also that the 
public authorities may be able to describe and to trace him. 

Therefore, the great facts of his being, his birth, marriage, and death, should 
be put on record with as many circumstances respecting him and these events 
as will show beyond doubt his origin and connection. The first record, that 
of birth, should contain the date and place of the event, the name and sex of 
the child, the names of both parents, the occupation of the father. The 



1852.] 



Births, Marriages, and Deaths in Massachusetts. 



151 



second, that of marriage, should show the names, birth-place, ages, residence, 
parentage of both parties, the occupation of the husband, the date and place 
of the ceremony, the name of the person by whom it was performed, and 
whether this be the first or any subsequent marriage of either party. The 
final record, that of death, should show the date, place, and cause of death, 
the sex, age, occupation, and civil condition of the deceased, and where the 
interment took place. 

These are the primary facts which should be registered and returned to 
the State or national authority. Then they can be so arranged and combined 
as to admit of a great variety of deductions very important to humanity. 

The value or the expectation of life may be determined or rather approxi- 
mated by these facts. The average duration of life in any place or among any 
people is modified by many other facts and circumstances, and mostly by the 
composition of the population. Thus, if a town or State be new, and composed 
mostly of youth and young families, the bills of mortality will be filled mostly 
with persons in the early periods of life. The average longevity of those who 
die in such a community would of course be less than in an older State, which 
included a due proportion of persons in the older and more advanced periods 
of life. In a stationary population, where none come in except by birth, and 
none go out except by death, and where it has been so during the period of 
the longest possible life, this average longevity of the deceased is a fair crite- 
rion of the chance of one's existence there. But in proportion as immigra- 
tion brings any in, and increases the ratio of any class, or as an emigration car- 
ries any out and diminishes the proportion of any class, this average is lower 
or higher according to the kind and degree of the disturbing element. 

Nevertheless, imperfect as may be the deductions made from these data, 
they are still of value, and in the hands of cautious reasoners they will be of 
great service. Therefore, we need to have the precise age of each deceased 
individual stated, and the whole presented in tables and classes of very small 
periods. 

A table containing the ages in classes connected with the causes of death 
shows at what period of life certain diseases are fatal or otherwise. 

A table showing the ages in classes connected with the counties, towns, or 
other localities shows with what different degrees the local morbific and fatal 
influences press upon human life at the various periods of existence. It is an 
admitted and perhaps an established fact that residence in a compact city is 
less favourable to infant life than a residence in the open country. Massa- 
chusetts seems to be more favourable to the developing and forming periods 
of life under 20 years than England, Denmark, and some other countries of 
Europe ; but on the other hand, it seems to be less favourable to life during 
the period of action and responsibility from 20 to 60 years than those other 
nations. Differences of this nature between localities, districts, and countries 
of different character might be shown by an extended and complete arrange- 
ment of the bills of mortality according to this plan. 

The ages connected with diseases show how far the causes of death affect 
the various periods of life. Thus, convulsions and hydrocephalus prevail 
mostly in childhood ) consumption in the third and fourth decade of life ; and 
apoplexy and palsy in the later periods. 3Iany other and important prin- 
ciples of this nature might be elicited and established by this arrangement. 

A table, combining age, locality, and disease, would show whether the causes 
of death have the same influence in various places. Dysentery may be more 
fatal to childhood in one place, and to adults in another. 

Combining disease with occupation shows whether the former have any 



152 



Reviews. 



connection with the latter, and to what extent. Age with occupation shows 
whether the circumstances or the exposures of one are more injurious to life 
than those of another. 

The date of death standing alone is important as showing the effect of the 
seasons upon life ; connected with the age, it shows the effect of the season 
upon the different periods, as the warm season is usually more fatal to 
infancy, and the cold season to old age. The date connected with disease 
shows when the different maladies prevail ; as diseases of the digestive organs 
are commonly more prevalent in the summer and early autumn, and pulmo- 
nary diseases in the winter and early spring. The date in connection with 
locality shows the effect of season on various places; as the summer may he 
more unfavourable to the city, and the winter to the country. 

The sexes should be exhibited in all these various combinations to show 
the influence of age, locality, disease, and season upon males and females. 

The localities should be as small as the divisions of the country will admit. 
It is not enough that these facts should be given in counties, but they should 
be given in towns and if possible in smaller districts, in order to define with 
the utmost exactness the degree and kind of local influences. If the diseases, 
&c,, of Massachusetts and New York were stated as they are in England in 
towns, it would be easy to group all the mountainous towns into one class, and 
all those in dry plains in another, and all those in swampy and marshy districts 
or along the low borders of sluggish rivers in another, and those on the sea- 
coast in still another; and thus the local influences could be determined. 
Some of the counties in these States include several or all of these varieties of 
country. The County of Middlesex in Massachusetts extends from the sea- 
coast on the east more than forty-five miles westward to the almost mountain 
region of the interior. 

In order to present the results at one view, all the localities should be 
grouped and arranged in classes according to their natural and artificial affini- 
ties. Those on the sea-coast should be in one class, those in the interior in 
another, those in the mountainous regions, those along the low banks of slug- 
gish rivers, exposed to bogs, and perhaps to miasmata, those on the level and 
dry plains, the compact cities and towns, and the sparse rural districts, the 
manufacturing and the commercial districts, all these should be arranged in 
distinct classes, and then the various circumstances and combinations of cir- 
cumstances, as age, disease, season, sex, &c, stated in connection with them. 

These tables would show whether there are any, and how great may be the 
difference of the morbific influence in these several classes of localities, and 
lead to the investigation of the nature and character of these influences or 
causes of disease. The fact that a definite disease exists or prevails in one 
district, or in one range of circumstances, and not in another, justifies the 
necessary inference that the cause of disease exists in the former, and not in 
the latter, yet it does not explain what that cause may be. This is a matter 
of further inquiry. But this may be limited to the conditions or circum- 
stances or habits that are to be found in the locality where the disease pre- 
vails, and not in the other where it was not. 

The excess of mortality from typhus fever, cholera, and dysentery, in the 
narrow lanes, closed courts, and crowded dwellings of some of the poor in 
Liverpool, London, and other cities of Great Britain and elsewhere, led to 
the examination of those localities and dwellings,' and revealed their foul air 
laden with animal exhalations, the absence of household and personal cleanli- 
ness, and the privation of comforts which the occupants endured. These 
being found almost universally in such places, and these malignant and viru- 



1852.] 



Births ; Marriages, and Deaths in 31assaehusetts. 



153 



lent diseases of depression being found more there than in the broad, open, 
and clean streets, and the airy and comfortable dwellings that border upon 
them, lead to the natural supposition that these are the causes of this class of 
disease. 

The large excess of mortality from consumption among females over that 
among males, opens to the inquiry whether the female organization renders 
women more susceptible of this disease than men, or whether the female cos- 
tume that covers the neck and chest less, or her habits of in-door life or want 
of frequent and vigorous exercise, expose her more than the male to this 
malady. 

If we could obtain a registry of mortality from consumption in countries 
where the habits of the two sexes, in regard to occupation and labour, are 
nearly alike, and women work with the men in the field, this would deter- 
mine the influence of one of the circumstances, and show whether in-door life 
and comparatively inactive habits have any influence in producing this dis- 
ease. If in such a country there should be found as great a disproportion of 
phthisis in the two sexes as here where their habits differ so widely, it would 
lead to the conclusion that these habits had no such injurious influence as is 
here supposed. But if it should be found that in those countries where 
women laboured abroad like men, they had no more consumption than their 
brethren, it would be reasonably concluded that the in-door and quiet life in 
other places opened the way to the attack of this disorder. 

Much light might be derived from a registration of mortality and its causes 
among the field slaves of the South, where the employments and habits of the 
sexes are very nearly alike. 

These facts increase in value with their increasing numbers. The greater 
the number of cases presented in which certain facts are associated with or 
follow certain conditions, the more true is the deduction that these facts be- 
long to or grow out of those conditions, and that the one is the cause and the 
other the consequence. We need, therefore, not only the record of the mor- 
tality and the attendant conditions and circumstances from a single district and 
for a single year, but we want this to cover as many districts and include as 
many people as possible, and also that the experience and observations of each 
successive year should be added to those of all preceding years. 

When the groups or classes include only a few facts, the deductions from 
one may differ very much from those drawn from another. Thus in the Mas- 
sachusetts reports, the tables of the average longevity of persons engaged in 
various occupations, show a great and enormous difference, in different years, 
in some occupations which include but few; but in those occupations which 
include many, there is nearly the same average from year to year. 

Having thus stated what is desirable in these registration reports, it is worth 
while to examine those already published, and see what they have done and 
how near they come to the proposed ideal. 

The primary facts from the districts and towns required by the law and 
gathered by the clerks, are nearly the same in both Massachusetts and New 
York, and through all the years in which they were obtained. But there 
may be a great difference in the manner in which these original facts are di- 
gested and presented to the world. There is a great variety of ways in which 
they may be arranged and combined, and in the deductions that may be made 
from them. This work of preparation should then be entrusted to such per- 
sons as thoroughly understand and appreciate this branch of vital and statisti- 
cal science; such as can add experience in this matter to a careful study of its 
means and objects. A suitable person, having a clear conception of what 



154 



Reviews. 



should be done with, and what advantages may be derived from, these facts, 
would begin with a well-digested and comprehensive plan, and carry it out 
from year to year, and thus annually add new value and new strength to the 
principles that may have been set forth and established. The registration 
officer should, therefore, be selected as a judge or a professor, for his pecu- 
liar fitness for the office, and his term of office should be secure from all 
change, because every year's experience makes him more valuable. 

Unfortunately, neither in Massachusetts nor in New York is a special of- 
ficer appointed for this purpose \ but in both it is left in the hands of the Secre- 
tary of State, whose office is a political one, and liable to be changed with the 
success or defeat of political parties. 

The nine reports of Massachusetts have been prepared and published under 
the direction of four different secretaries, and as this officer is necessarily 
overburdened with the duties required of him by the law and custom, he is 
obliged to delegate this work of digesting the returns of births, marriages, and 
deaths, to some subordinate officer or agent. These nine reports have been 
prepared by almost as many hands ; consequently, they differ in their character 
and purpose. No two of them are alike. No single plan has been adopted 
and carried through all. Each one of the reports is valuable in itself; but 
they, collectively, do not form one whole. Each successive report is not 
made more valuable than its predecessor by including the sum of all previous 
facts and observations, and thereby strengthening its own deductions. Al- 
though these reports have a general similarity, and a seeming sameness of 
purpose, and satisfy the wants of most persons, especially those who look at 
them only to learn the bare facts of the year reported, yet those who desire 
to learn from them the permanence or change of facts, to draw safe deduc- 
tions, and establish principles on the broadest foundation, are disappointed. 

The population, births, marriages, and deaths of Massachusetts, in each 
town and county, during the year reported, is stated, in one table, in all the 
reports but the third. 

The population and births, population and marriages, and population and 
deaths, in each town and county, are stated in three separate tables in the 
third report. 

The same table includes the births, marriages, and deaths, during each of 
the two previous years, separately, in the fifth, sixth, seventh, and that part of 
the eighth report that includes these events during the eight months next suc- 
ceeding May 1st, of 1848. In the fourth report the table includes these 
facts during the three previous years. But this mention of the facts is omitted 
in that part of the eighth report that includes the events of 1849, and in the 
ninth report. 

The births in each town and in each month are stated in the third report. 

The births and sexes in each county are stated in the third and all subse- 
quent reports. The same is stated in regard to each town in the third. 

The plurality cases of birth, with the sexes in each county, are stated in 
the third. 

The same facts in each month are in the fourth and all subsequent reports. 

The third report informs us how many children were born whose fathers' 
occupation was reported to the Secretary of State. But this is all. We are 
only told how much the Secretary knows, and how faithful the people have 
been in instructing him. But what he knows, what his facts are, we are not 
informed. It might be desirable to know what proportion of the births was 
in families of the various social conditions, and engaged in the various occu- 
pations. 



1852.] Births, Marriages, and Deaths in Massachusetts. 155 



The marriages in counties and months, and the previous condition of each 
party, whether single or widowed, is stated in the third and all subsequent 
reports. 

The ages of the marrying parties, in classes, are in the fourth and all fol- 
lowing reports. 

The average age of the marrying parties in each condition of first, second, 
or third marriage, is in the third report. 

The nativity of the marrying parties in each town, whether native or foreign, 
is stated in that part of the eighth report that relates to 1849, and in the 
ninth relating to 1850. 

In none of these reports are the facts of the preceding years brought to- 
gether to show, at one view, the proportion of first, second, and third mar- 
riages of each sex, in different months, at the various ages, or in the different 
counties. 

The same variance of plan and execution, the inclusion of some facts in 
some years, and their omission in other years, is shown in the reports of the 
deaths. 

The population and mortality is given, for each town, in all the reports. 

The deaths, in each of the two previous years, are stated in the third, fifth, 
sixth, and seventh reports, and those of the three previous years are in the 
fourth. 

In all these five reports these facts are stated separately for each year. But 
in the report for 1848, the deaths, in the three years, are stated in the aggre- 
gate, and the average for each year is shown. And in the reports for 1849 
and 1850, no mention is made of the mortality of the previous years. 

The ratio of mortality to the living in each county, and also in two divi- 
sions of eastern and western counties, for 1849, is stated in the eighth re- 
port. 

The sexes of the deceased, in each town and county, for the years 1848, 
1849, and 1850, separately, are stated in the eighth and ninth reports. 

The sexes of the deceased, in each month and each county, are stated in 
the third, eighth, and ninth reports. 

The ages in classes, in respect to counties, are in the second, third, and 
fourth reports. 

The ages, in respect to diseases, are in all the reports. 

The diseases, in respect to counties, in respect to months, and in respect to 
ages, are in all the reports; but they are stated as separate facts. 

The diseases, in respect to sexes, are stated in the fourth and following 
reports. 

The diseases in respect to birth-place, whether native or foreign, are in the 
fourth, fifth, sixth, and seventh reports. 

The diseases in city and in country are shown, for the year 1849, in the 
eighth report. 

The whole number of deaths from each disease, and the proportion of 
those from each disease to the total deaths, in the year 1849, in the eight 
months of 1848, and during the seven previous years, are stated separately 
in the eighth report. Similar statements for 1850, 1849, and the seven pre- 
ceding years, are in the ninth report, and for three years separately, in the 
fourth, fifth, sixth, and seventh reports. 

The average age of the deceased, for the reported year, is stated, in respect 
to towns, in the third, eighth, and ninth reports, and in respect to counties 
and the State in the third, fourth, eighth, and ninth reports. And also the 
average longevity of the married and of the unmarried, who were over twenty 



156 



Reviews. 



[July, 



years old, is in the fourth, fifth, sixth, and seventh reports. The average 
longevity, in some towns in America, and England, and Genoa, including a 

series of years, is in the fourth report. 

The average age of males over 20, in the several occupations, is in all the 
reports for each year. That of females, in some occupations, is in the fourth 
and following reports. 

The same is stated for the two preceding years, separately, in the fourth, 
fifth, sixth, and seventh reports. This average for the year 1849, and the 
eight months of 1848, in one column, and for the five preceding years in 
another column, is stated in the eighth report. It is stated, for the year 1850, 
in one column, and for the preceding six years and eight months, in another 
column, in the ninth report. 

Dr. Josiah Curtis, of Boston, to whom, fortunately, the preparation of the 
eighth report was committed, added to that several valuable tables, showing, 
among other things, 

The number and proportion of native and foreign population in Massa- 
chusetts, at the three several censuses of 1830, 1840, and 1850. 

The number and proportion of natives and foreigners, the population to the 
square mile, the dwellings, and barns, in 1850 ; the number and ratio of 
births, marriages, and deaths, to the living, in 1849, in each county. 

The number of births, of foreign and native parentage, in the cities and 
large towns, and in the rural districts ; and also the number and average age 
of persons dying in the same in 1849. 

Comparative ratio of male and female births in the eastern or sea-coast 
counties, and in the interior, in the cities and in the country. 

Number and sex of persons dying of consumption and of dysentery in 
each month. 

Number and proportion of deaths of each sex, at the several periods of life, 
in the city and in the country. 

Thus we see that these nine reports of Massachusetts afford a great amount 
of facts, and ground for many deductions as to the progress of population and 
mortality. 

And yet, though so much is done, there is much more to be desired. There 
was no clear and definite plan in the beginning; none which, being once 
adopted at any time, has been carried out through all the subsequent reports, 
adding the experience of each year to the gathered experience of the preceding 
years. Each successive officer seems to have arranged the work according to 
his own notions, and made such exhibitions of the facts that were received, 
and drawn such deductions from them as seemed to him, at the time, most 
important, without regard to the plan and the work of his predecessors. 

Consequently, although, from the returns made to the Secretary of State, 
sixty-five facts or combinations of facts and deductions are stated in one or 
more of the reports, and might have been advantageously stated in all, only 
seventeen of these are presented in all the reports. Of the others, some are 
given in only one, some in only two or three reports; some are presented, then 
omitted and presented again ; and others are brought out in the third or later 
report, and continued in all that follow afterwards. 

In regard to none is the sum of the observations of the previous years 
added to those of the reported year, and the deductions drawn, and'the prin- 
ciples established, from the largest amount of data. This is singularly shown 
in the tables of longevity, both of the whole number of persons dying and 
of those in the several occupations. The statement of the average duration 
of life is valuable as a reliable principle only when it is taken from a large 
number of persons, and the more the facts are multiplied, the more nearly 



1852.] 



Births, Marriages, and Deaths in Massachusetts. 



157 



does their average approximate the truth, and increase the value of the de- 
ductions drawn from them. 

It would seem, therefore, to be the most reasonable plan to include, in this 
calculation of the longevity of the deceased, in any state, county, town, or 
class, all who had been known to have died in the places or conditions under 
consideration. But, in the first seven reports, only the facts, the number of 
deaths, and the average age of the deceased in the various occupations, in a 
single year, are presented as the basis of calculation. 

In the fourth report, these facts for 1845, and also for 1844, 1843, and 
1842, are stated in four separate columns. In the fifth, sixth, and seventh 
reports, the same facts for the reported years, and for each of the two preced- 
ing years, in three separate columns, are stated. 

In the eighth report, the deaths, during the twenty reported months, in the 
several occupations, are included in one sum and column of sums, and those 
during the five previous years in another sum and column of sums, and the 
average drawn from these separately. In the ninth report, these facts are 
stated, and averages drawn from the facts of 1850, and of the previous six 
years and eight months, in two separate columns. In neither of these reports 
is the whole sum of the facts added, and the average drawn from this the 
widest field of observation. 

Where the observations are few, in each year, their averages differ. Thus, 
the longevity of the furnace men is stated to be 22 years in 1846, and 63.75 
years in 1847. That of gunsmiths was 30 years in 1844, and 80 years in 
1846. That of bookbinders was 29 years in 1845, and 66 years in 1848. 
These are extreme specimens; but they show the error of taking averages from 
a small number of facts. But, in some other occupations which include large 
numbers of deaths, the average approaches a similarity that indicates the value 
of the inference. Thus, the agriculturists, farmers, and gardeners, whose 
deaths, during the nine years and eight months reported, were 7150, averaging 
735 a year, had an average longevity of 66, 66, 64.02, 61.64, 61.64, 66.63, 
65.41, 62.39, and 65.93 years. The 1008 carpenters who had died during 
these successive years had an average longevity of 62, 48, 51.52, 52.26, 
48.94, 48.01, 47.56, 48.94, and 49.61 years. 

The two reports which we have from New York are for the years 1847 and 
1848. Since the last date no returns have been made to the Secretary of 
State, and of course no report has been published. The law is not repealed, 
but it is inactive. It had not time during its two years of operation to take 
such hold upon the people as would convince them of its usefulness. 

These two reports' are the same for both years. They present the same 
facts, the same tables, and the same deductions. There are five tables. 

The first includes the population, births, marriages, and deaths, in each 
town and county. 

The second states the births, in each county, 1st, in each month; 2d, the 
sexes and colour of each sex; and 3d, the number of illegitimate. 

The third shows the marriages in each county. 1st, as to months; 2d, as 
to color and sex ; 3d, the approximate ages of each sex. 

The fourth shows the deaths in each county. 1st, as to months ; 2d, as to 
colour of each sex; 3d, the married and unmarried of each sex; 4th, number 
in each profession, and average age in each profession in the whole State. 

The fifth states the deaths, 1st, diseases, ages, and sexes ; 2d, diseases, 
month, and sex; 3d, diseases, nativity, and sex. 

The plan of the first report is carried out in the second. But each one 
stands alone. In the second, no reference is made to the first. The average 
No. XLYII.— July, 1852. 11 



158 



Reviews. 



[July, 



age of the last is based solely upon the experience of that year ; and no 
opportunity is there offered for comparing the facts and experience of 1848 
with those of the previous year. 

The ninth report of Massachusetts is more full than any of its predecessors. 
It is so complete that the secretary enters into the calculation of the ratio of 
births, marriages, and deaths, to the whole living population. In 1850 there 
were 27,664 births, 10,345 marriages, and 16,606 deaths, in all the cities 
and all the towns but eight, the whole containing a population of 975,578. 
Calculating the ratio in the eight unreported towns by the ratio of the other 
rural districts, there were in the whole State 28,172 births, 10,538 marriages, 
and 16,901 deaths in the year 1850. Tbis was one birth in 35.31, one mar- 
riage in 94.52, and one death in 58.85 of the living. 

The rate of mortality in the city of Boston was one in 37.32 ; in the rest 
of the State, one in 64.81. In the cities of Boston, Lowell, Cambridge, 
Charleston, and Boxbury, this rate was one in 42.74; in the rest of the State, 
one in 65.41. 

The mortality was more in 1849, being 20,423, or one in 45.58 of the 
calculated population. 

The mortality was at an earlier age generally in 1849 than in 1850. Of 
all the deceased, 39 per cent, were under 5 years of age, 50 per. cent, under 
20, and 16 per cent, over 60, in 1849. And 37 per cent, were under 5 
years, 47 per cent, under twenty, and 18 per cent, were over 60 years of age 
in 1850. The average longevity was 26.19 years in 1849, and 27.67 in 
1850. 

The cholera, dysentery, and other diseases of the digestive organs prevailed 
in 1849 more than in other years. In that year 1188 died of the cholera, 
360 of cholera infantum, 2455 of dysentery, and 209 of diarrhoea, making 
4063 of these diseases, and about 20 per cent, of all from known causes. 
The mortality from all diseases of the digestive organs was 6,143 or 30 per 
cent, of all. 

In 1850, the deaths from cholera were 65; cholera infantum, 252; dysen- 
tery, 1188 ; diarrhoea, 172; in all 1677 ; and 11 per cent, of all from known 
causes. The total mortality from diseases of the digestive organs was 3,438, 
or 21.88 per cent, of all. 

The mortality from the zymotic diseases, including the endemic, epidemic 
of contagious disorders, was 7,520, or 38 per cent, of all from known causes 
in 1849, and 4,357, or 27 per cent, of all in 1850. 

The mortality from pulmonary diseases was about the same in both years, 
being in 1849, from consumption, 3606; pneumonia, 815; other diseases of 
the lungs, 759; in all, 5,180. In 1850, the deaths were, from consumption, 
3,257; pneumonia, 838; other diseases of the lungs, 832 ; total, 5,297. It 
is manifest that the deaths from this class of causes have a much larger pro- 
portion to the whole mortality in 1850 than in 1849; being of consumption, 
22 per cent, in 1850, and 17 per cent, in 1849; and of all 32 per cent, in 
1850, and 25 per cent, in 1849. Compared with the whole population, from 
which returns were made, the deaths were from diseases of the digestive 
organs, one in 151 in 1849, and one in 183 in 1850; from diseases of the 
lungs, one in 179 in 1849, and one in 184 in 1850. The mortality from the 
zymotic class was 7,520, or one in 123, of the people in 1849, and 4,357, 
or one in 224 in 1850. 

Locality. — The effect of locality, or the power of local influences may be 
traced to a certain degree in these reports. Massachusetts covers but a small 
extent of territory, but there are marked differences in its character. Its 



1852.] 



Births, Marriages, and Deaths in Massachusetts. 



159 



length from the sea-coast westward to the line of New York is only about two 
hundred miles. The country near the Atlantic is low and level through Barn- 
stable, Plymouth, Bristol, Nantucket, and Dukes Couuties, and hilly but not 
high, through Norfolk and Essex Counties. The interior is higher and more 
hilly, and some of it, especially the region west of the Connecticut River, is 
mountainous. The eastern division is exposed to the east winds, which are 
chilly and oppressive to those who are subject to pulmonary diseases. The 
western division is more out of the reach of these winds, and mostly protected 
from them by the high lands of Worcester County, which run through the 
State from New Hampshire to Connecticut. 

The eastern counties contain many large towns and some cities ; and the 
population of the whole is much more dense than that of the western counties. 
A large proportion of the inhabitants of the eastern sections are engaged in 
trade, commerce, and manufactures ; while those of the western sections are 
principally employed in agriculture. The seven Atlantic counties, Essex, 
Norfolk, Plymouth, Barnstable, Bristol, Dukes, and Nantucket contained in 
1850 a population of 390,579, and 164 to the square mile. The five interior 
counties, Worcester, Franklin, Hampshire, Hampden, and Berkshire, contained 
294,308 inhabitants, and 60 to the square mile. Boston has 136,884 people. 
Middlesex County, with 161,385 inhabitants, includes the cities of Cam- 
bridge and Charlestown, and some large towns bordering on the bays and the 
sea-coast, and also a wide agricultural territory extending to the highlands in 
the interior. This county, therefore, belongs exclusively to neither of the 
divisions herein described. 

The returns of the deaths, for the years 1849 and 1850, are sufficiently 
complete to justify a calculation of the rate of mortality in the towns that 
were reported. Taking the average of those two years, and comparing this 
with the average calculated and enumerated population, we have the facts of 
the deductions in the following table : — 



Average Annual Mortality in Massachusetts in the years 1849 and 1850. 





Interior 


Sea- 


COAST 


City of Boston. 




Counties. 


Counties. 






Average population for 1849 














and 1850 


284,663 


371,885 


134,819 




Mortality. 


Mortality. 


Mortality. 


Causes of death. 


No. of 


In 10,000 


No. of 


In 10.000 


No. of 


la 10,000 




deaths. 


living. 


deaths. 


living. 


deaths. 


living. 


All causes 


5113 


179 


6194 


152 


4373 


324 


Zymotic diseases 


1754 


61.6 


1759 


47 


1666 


123 


Diseases of digestive organs 


1255 


44 


1177 


31 


1078 


799 


Diseases of respiratory organs 


1420 


51 


1928 


51 


1088 


80.7 


Consumption 


1003 


35 


1415 


38' 


615 


45 



It appears from these facts that the rural districts, near the seacoast, were 
more favourable to life, during these two years, than the interior. But the 
rate of mortality, and especially from diseases of the zymotic class and of the 
organs of digestion, in the city of Boston, was more than twice as large as that 
of the other Atlantic districts. The mortality from endemic, epidemic and 
contagious diseases, and from all diseases of the digestive organs, was more in 
the interior than on the sea-board. Consumption was somewhat more fatal on 



160 



Reviews. 



the sea-coast than in the counties distant from the ocean, and considerably 
more prevalent in the city than in the country. 

The average longevity appears to have been nearly the same on the sea- 
coast and in the interior. The average age for each county is stated in the 
reports for the years 1843, 1849, and 1850, and the periods within which 
the deaths took place in the several counties are given in the reports for 1841 
and 1842. From these last, the average age can be calculated. Hence we 
obtain the number of deaths, and the average longevity in the different dis- 
tricts of the State, as in the following table. The numbers in regard to 
Boston are taken and calculated in part from the city bills of mortality, and 
include nine years from 1842 to 1850. 

Mortality of Average Longevity in Massachusetts. 

Number of Deaths. Average Longevity. 

Seven Atlantic counties, five years . . . 22,419 31.8 

Five interior counties, five years .... 18,397 32.13 

Boston, nine years 27,545 21.27 

Middlesex, five years 9,766 27.13 

By this, we see that there was, during these periods, but little difference in 
longevity produced by the exposure to, and protection from, the atmosphere 
of the ocean. But there is in this respect a very marked difference between 
the city and the rural districts, whether on the sea-board or in the interior. 
The longevity was fifty per cent, greater in the country than in Boston. Mid- 
dlesex County, which includes the cities of Lowell, Charlestown, and Cambridge, 
as well as its open districts, shows an average longevity approaching a medium 
between the others. Probably a part of this difference is due to the fact 
that Boston and Middlesex have both grown much more rapidly, within the 
last ten years, than the rest of the State. They have, therefore, among their 
population a larger proportion of the middle-aged, the young, and children, 
whose natural and necessary mortality would diminish the average longevity 
of the whole. They have also a large, and Boston a very large foreign popu- 
lation, mostly Irish, whose early marriages and numerous births increase the 
subjects of early death, and diminish still farther this apparent longevity of 
the whole people. 

Influence of Seasons. — The influence of the seasons, the cold and the warm, 
is observable in these registers, in respect to the mortality from diseases of the 
digestive and the respiratory organs. This is more marked in regard to the 
former than in regard to the latter. 

In the warm season, from May to October, inclusive, the deaths, from all 
diseases of the digestive organs, were, in Massachusetts, during the nine 
entire registered years, 18,831; in New York, during 1847, 1848, they were 
3793 ; and, in both of these States, 22,624. During the cold seasons, from 
November to April, inclusive, the deaths from these causes were, in Massa- 
chusetts, 5,105; in New York, 905; and in both, 6010. 

There was much diversity in the proportions of mortality in winter and in 
summer, from the various diseases of this class. The greatest difference was 
in regard to dysentery, from which 9515 died in the warmer, and 715 in the 
colder months. There was nearly the same disproportion of deaths from cho- 
lera and cholera infantum, being 3592 in summer, and 263 in winter. The 
mortality from diarrhoea and bowel-complaints had a similar, though a smaller 
disproportion as to seasons. On the contrary, there were more deaths from 
colic, dyspepsia, organic diseases of the stomach, worms, and diseases of the 
liver in the cold than in the warmer parts of the years. 

The mortality from diseases of the respiratory organs was greater in winter 



1852.] 



Births, Marriages, and Deaths in 3Iassachusetts. 



161 



than in the summer, being 14,744 in Massachusetts, 4605 in New York, and 
19,349 in both, during the six months, from May to October; and 16,285 
in Massachusetts, 5151 in New York, and 21,436 in both, during the six 
months from November to April. 

The greatest difference was in the mortality from pneumonia, being 3770 
in winter, and 1794 in summer; and from croup, which was 2028 in the cold, 
and 1251 in the warm season. The deaths from pleurisy, bronchitis, and 
influenza, were more in the winter than in the summer. But the other dis- 
eases of this class, consumption, hooping-cough, catarrh, and hydrothorax, 
were somewhat more fatal in the warm than the cold season. The mortality 
from consumption, during the six warmer months, was, in Massachusetts; 
11,462; in New York, 3271, and in both, 14,733 ; and during the six colder 
months, in Massachusetts, 10,597; in New York, 3278, and in both, 13,875. 
Hooping-cough destroyed 810 in the warm season, and 543 in the cold. 
These are important matters, and deserve a farther investigation, to see how 
far these diseases are influenced by the seasons. These facts from Massa- 
chusetts and New York lead to the suspicion, at least, that winter is no more 
fatal to consumptive patients than summer. In London, during three years, 
the deaths from consumption were, in the first and last quarters, October to 
March, 10,748 ; and, in the second and third quarters, from April to Sep- 
tember, 11,271. 

The proportion of mortality from various causes to the whole population 
cannot be determined here for want of complete returns from those States 
and towns which are reported. But the ratio of effect of these causes to each 
other can be shown, and it will be seen that they differ in different places and 
countries. 



Distribution of Mortality from various Causes. 



CAUSES. 


Massachusetts. 

Nine years and 
eight months. 


New York. 

Two years, 
1847 and 1848. 


England & Wales. 

Five vears, 
1838 to 1S4-2. 


Deaths. 


Ratio. 


Deaths. 


Ratio. 


Deaths. 


Ratio. 


All specified diseases 


92,984 


10,000 


29,449 


10,000 


1,692,251 


10,000 


Zymotic 


27,415 


2,948 


9,316 


3,159 


336,727 


1,989 


Uncertain seat 


11,281 


1,213 


2,701 


919 


236,259 


1,396 


Nervous organs 


8,73G 


939 


3,118 


1,059 


249,905 


1,476 


Respiratory organs 


26,226 


2,820 


8,516 


2,893 


459,472 


2,715 


Circulative " 


1,825 


196 


433 


147 


21,191 


125 


Digestive " 


5,740 


617 


1,733 


588 


108,583 


641 


Urinative " 


386 


41 


108 


36 


8,398 


49 


Generative " 


1,094 


117 


210 


71 


17,193 


101 


Locomotive " 


466 


50 


187 


63 


10,850 


64 


Integumentary " 


116 


12 


34 


10 


2,418 


14 


Old age 


6,115 


657 


1,589 


538 


182.492 


1,078 


Violent 


3,584 


386 


1,344 


456 


58,763 


347 


All digestive 


16,234 


1,744 


4,905 


1,665 


132,035 


780 


All respiratory 


29,614 


3,184 


10,059 


3,417 


525,956 


3,108 


Cholera and cholera infantum 


3,380 


364 


193 


65 


3,490 


20 


Dysentery 


6,056 


651 


2,240 


760 


3,068 


18 


Fevers 


7,186 


762 


2,492 


846 


S3,092 


491 


Scarlatina 


4,259 


458 


1,064 


361 


62,911 


371 


Measles 


682 


73 


295 


100 


42,413 


250 


Croup 


2,016 


216 


1,132 


387 


21,625 


127 


Hooping-cough 


969 


104 


343 


116 


39,594 


233 


Consumption 


20,864 


2,243 


6,713 


2,299 


296,390 


1,751 



162 



Reviews. 



[July, 



So far as these facts admit of any inference, there is some difference in the 
ratio of prevalence of various diseases in England, New York, and Massa- 
chusetts. The endemic, epidemic, and contagious diseases bear a much 
larger proportion to the whole in these States than in England. The diseases 
of the nervous system were comparatively more frequent there than here. 
The diseases of the respiratory organs were relatively more abundant in New 
York than in Massachusetts, afnd the same in Massachusetts as in England, 
being severally 34, 31, and 31 per cent, of all. Consumption destroyed 22 
per cent, of all that died here, and only 17 per cent, in England. Measles 
were comparatively more than three times as fatal in England as in Massa- 
chusetts, and more than twice as fatal in England as in New York. On the 
other hand, croup was more than three times as destructive in New York, and 
almost twice as destructive in Massachusetts as in England. Fevers were 
comparatively 70 per cent, more fatal in New York, and 55 per cent, more 
fatal in Massachusetts than in England. Violent deaths occurred in a less 
varying proportion, being, in Massachusetts, 386 ; New York, 456 ; and in 
England, 347 in 10,000 of all from known causes. There was a greater dif- 
ference in the mortality from diseases of the digestive organs, being propor- 
tionately more than twice as great in these States as in England, and more 
in Massachusetts than in New York. The most remarkable difference is in 
the mortality from dysentery. This was in ratio of all, thirty-six times as great 
in Massachusetts, and forty-two times as great in New York as in England. 

The mortality from old age was in a larger proportion in England than in 
the United States, being 100 percent, greater than in New York, and 64 per 
cent, greater than in Massachusetts. This difference is due in part to the 
difference of population, for it is newer, younger, and more progressive in New 
York than in Massachusetts, and more stationary in England than in either. 
The English population, therefore, includes more in the later periods of life 
who may die of old age than the American. Nevertheless, the difference is 
too great to be wholly attributable to this fact. The number of persons over 
70 years old in 1000 of all ages, were 16 in New York, 27 in Massachusetts 
in 1840, and 28 in England in 1841; whereas the ratio of deaths from old 
age was, in New York, 53; in Massachusetts, 65; and in England, 107 in 
1000 deaths from all causes. The ratio of persons who were over 70, and 
therefore subject to die of old age, was, in New York, 100; in Massachusetts, 
166; and in England, 175. The equal ratio of mortality from this cause, in 
these States and England, respectively, should be 100, 184, and 175; whereas 
it is as 100, 122, and 200. Massachusetts then fell far short of, and Eng- 
land somewhat exceeded, the ratio of New York in the mortality from 
old age. 

The average longevity of males over twenty years old, dying in the various 
professions and occupations, is stated in all the reports of Massachusetts and 
New York. It would be unprofitable to present here the longevity of each 
and all of these employments, for many of them included too few persons to 
allow any confidence to be placed in the deductions that may be drawn from 
them. Yet these employments may very properly be arranged into classes, 
according to the similarity of habits which they require, and the exposures to 
which those who are engaged in them are subjected. These classes are as 
follows : — 

I. Farmers and gardeners, cultivators of the earth. Their habits are active 
and often laborious. They labour in the open air. They have the means of 
comfortable living, and are generally free from oppressive anxieties. 

II. Labourers, servants, brakemen, chimney-sweepers, coachmen, stage- 
drivers, hostlers, well-diggers, and workmen in powder-mills. These are gene- 



1852.] Births, Marriages, and Deaths in Massachusetts. 163 



rally the poor. Their lives are laborious. They are mostly employed in the 
open air. They are subject to much care, and often to privations and dis- 
comforts. 

III. Active mechanics employed mostly in the open air. Boat-builders, 
bookmakers, carpenters, calkers, masons, millers, millwrights, riggers, saw- 
yers, ship-carpenters, stonecutters, and tanners. 

IV. Persons actively employed abroad on the land, but not as cultivators 
of the earth nor as mechanics. Army-officers, baggage-masters, butchers, 
colliers, drovers, engineers and firemen, expressmen, ferrymen, gate-keepers, 
light-house keepers, lumbermen, news-carriers, peddlers, pilots, sextons, she- 
riffs and constables, soldiers, stablers, stevedores, surveyors, teamsters, watch- 
men, weighers, and gaugers. 

V. Active in-door mechanics who have much and almost constant exercise, 
and are protected from the elements, and generally in warm shops. Axe- 
grinders, bakers, basket-makers, blacksmiths, bleachers, bloomers, book- 
binders, brush-makers, cabinet-makers, calico-printers, card-makers, carriage- 
makers, chaise-makers, coach-makers, chair-makers, churn-makers, cloth- 
makers, clothiers, comb-makers, confectioners, cooks, coopers, coppersmiths, 
curriers, cutlers, distillers, dyers, file-cutters, founders, furnacemen, glass- 
blowers, glass-cutters, gunsmiths, harness-makers, hatters, leather-dressers, 
machinists, maltsters, match-makers, morocco-dressers, nail-makers, paper- 
makers, painters, pianoforte-makers, pill-makers, potters, pump and block- 
makers, reed-makers, rope-makers, sail-makers, sash-makers, screw-cutters, 
soap-boilers, tallow-chandlers, tinsmiths, tobacconists, trunk-makers, turners, 
wagon-makers, weavers, wheelwrights, upholsterers, victuallers, and wool- 
sorters. 

VI. - Sedentary and quiet mechanics, &c, employed within doors. Artists, 
barbers, cigar-makers, dentists, engravers, goldsmiths, jewellers, operatives, 
portrait-painters, printers, saddlers, shoemakers, shoecutters, silversmiths, 
tailors, watch-makers, whip-makers, comedians, and musicians. Their em- 
ployments do not usually give them as much exercise as their health requires. 
They are protected from the elements, and are mostly occupied in warm shops. 

VII. Seamen employed on the ocean and the lakes — sailors, fishermen, 
and naval officers. They are exposed to severities of the weather, and occa- 
sionally to some privations. 

VIII. Merchants, traders, grocers, apothecaries, druggists, booksellers, 
stove-dealers, provision-dealers, clerks, manufacturers, speculators, bankers, 
bank-officers, brokers, capitalists, gentlemen, innkeepers, postmasters, railroad 
agents and conductors, ticket-masters, and superintendents of factories. Their 
occupations require little or no bodily labour, but some or much exercise of 
the brain. They are principally engaged in the affairs of trade ; in making 
or managing money, or watching the details of business. They are employed 
within doors, and can generally or always be protected from the elements. 

IX. Professional men, clergymen, judges, justices, lawyers, physicians, 
professors, teachers, students, civil engineers, editors, and public officers. 
Their occupations require much labour of the brain, and but little of the body. 
They are engaged much in abstractions and principles, and in the application 
of these to the common affairs of life. 

X. Mechanics, whose special occupations are not stated. 

The following table presents the number and the average longevity of the 
males, over twenty years old, who belonged to these several classes and are 
reported as having died in Massachusetts during the nine years and eight 
months ending with 1850, and in New York during the years 1847 and 
1848. 



164 



Revieics. 



Classes of Occupations. 


Massachusetts. 


New York. 


Mass. & N. York. 


Deaths. 


Av. age. 


Deaths. 


Av. age. 


Deaths. 


Av. age. 


I. Fanners, &c. 


7196 


64.58 • 


5180 


55.41 


12376 


60.8 


IT. Labourers, &c. 


3428 


45.44 


1324 


39.96 


4752 


43.7 


III. Active out of door me- 














chanics 


1701 


50.39 


208 


48.7 


1909 


50.21 


IV. Other active persons in 














open air 


330 


44.23 


48 


43.43 


378 


44.13 


V. Active mechanics, &c, in 














shops 


2086 


45.22 


248 


46.29 


2334 


45.36 


VI. Sedentary mechanics, &c, 














in shops 


1980 


37.7 


203 


42.48 


2183 


38.3 


VII. Seamen 


1717 


42.48 


54 


40.9 


1771 


42.42 


VIII. Merchants, financiers, &c. 


1626 


45.58 


362 


39.88 


1988 


44.53 


IX. Professional men, &c. 


650 


56.32 


427 


38.24 


1077 


49.26 


X. Mechanics, trades not spe- 














cified 


216 


43.66 


838 


45.1 


1084 


44.8 



Here is exhibited a great difference of longevity of men in the various 
classes of employment, and this is generally in favour of those who lead a life 
of action in the open air. The cultivators of the earth enjoyed the longest, 
and the sedentary mechanics, in warm shops, the shortest life. There is an 
observable distinction, in this respect, between the carpenters, masons, &c, 
mechanics whose occupation is laborious and abroad, and tailors, shoemakers, 
&c. ; whose employment is very quiet and under constant shelter. Assuming 
the lowest as the standard, the point of comparison, the table shows that while 
the sedentary mechanics lived 100 years, the seamen lived 110, the labourers 
113; the fourth class, butchers, drovers, stevedores, &c, lived 114; the mer- 
chants, &c, 115; the mechanics whose trades were not stated 116; the active 
in-door mechanics 117; professional men 127; active out-of-door mechanics 
130; and farmers and gardeners 157 years. 

Some part of this difference may be due to the difference of manner and 
times in which men enter and go out of some of these employments. In se- 
veral of those included in the fourth class young men are mostly employed ; 
many of these, after some years, go into other occupations, and there remain, 
and die at an older age. Yet, after making all proper allowance for these and 
other disturbing elements, there still remain remarkable differences of lon- 
gevity, which are connected with, and seem to belong to, these several classes 
of occupations. 

The facts stated in these reports are not sufficient to establish the deductions 
which have here been drawn from them as universal principles, nor even to 
demonstrate the extent to which they are applicable. But they are sufficient 
to demand farther investigation in the same field. It is, therefore, hoped that 
Massachusetts will continue to make her annual reports, that New York will 
revive the work which she has suspended, that Pennsylvania will carry into 
complete execution the law of registration which she has established, and that 
the other States will establish and execute similar laws for the registration and 
report of the births, marriages, and deaths, within their respective limits. 

These laws and reports will give to the world very many important facts, in 
respect to life and mortality. They will enable us to take the first step toward 
ascertaining the sanitary and morbific influences of seasons, atmospheric con- 
ditions and localities, of employments, social conditions, circumstances, and 
habits of the people. They will open the way to the discovery of the causes 
of disease, and probably to the means and methods by which they may be 
modified, ameliorated, and perhaps extinguished. E. J. 



1852.] 



165 



BIBLIOGRAPHICAL NOTICES. 

Art. XVI. — A Treatise on the Diseases of the Chest: being a Course of Lectures 
delivered at the New York Hospital. By John A. Swett, M. D. New York, 
1852: 8vo.pp.585. 

The lectures contained in this volume were published in the New York Lancet 
about ten years ago, but they now include much new matter derived from a 
register of the author's public and private practice since that period. Dr. 
Swett is well known as one of the first who introduced into New York the me- 
thods of physical exploration which he had learned in the schools of Paris ; he 
has continued to maintain a high character for skill and accuracy in the diag- 
nosis of thoracic diseases, and enjoyed opportunities surpassed by none other 
for perfecting himself in this department of medicine. Such vouchers for 
capacity and knowledge in the author inspire a degree of confidence in his work 
which a study of it will not diminish. 

The lectures treat in a concise manner of physical examination of the lungs 
and heart, and very fully of the acute and chronic affections of these organs. 
The great number of works that have been lately published upon the same sub- 
jects, and noticed in this journal, forbid our entering into a detailed analysis of 
the one before us, especially as the lectures do not claim a very recent origin, 
nor profess to institute a scientific inquiry which would call for a discussion of 
the principles and statements of authors, so much as to present in a clear and 
succinct manner what the author regards as established truths. Had he now 
to prepare a work upon the same subjects, he would, we apprehend, find reason 
to modify several of the doctrines, and to enlarge many of the statements con- 
tained in the one before us. Attention will be drawn to some of these points 
in the course of the present notice. 

In explaining the mechanism of the dry rhonchi, the author says "the bron- 
chi are rendered irritable by the existing inflammation, and being muscular 
tubes, at least in the smaller branches, they contract spasmodically at certain 
points," producing sonorous or sibilant tones according to the size of the 
tubes. And again, in speaking of bronchitis with obstruction to the pulmonary 
circulation, he remarks that this obstruction " seems to impress a peculiar irri- 
tability on the bronchi, by which the tendency to spasmodic contraction is mate- 
rially increased." (p. 57.) In another place, tartar emetic is said to operate 
usefully by counteracting " a tendency to spasm of the bronchi," (p. 62:) this 
condition is also stated to play " a most important part in the paroxysms of 
emphysema," (p. 195,) and we are told that " it is easy to conceive that a gene- 
ral spasm of the bronchi should induce" the dyspnoea of nervous asthma, (p. 
201.) The author furnishes no proof whatever of the correctness of an expla- 
nation of the dry rhonchi which we had supposed abandoned long ago, as purely 
hypothetical, and we notice this fact the rather because he is, in general, quite 
free from the prevalent vice of travelling beyond the record of facts and the 
inductions which legitimately rest upon them. 

The following explanation of oegophony is hardly admissible. " It seems to 
be produced by the vibrations from the bronchi being transmitted to the ear 
over the surface of the liquid effusion, like the ripple on the surface of a pool 
of water from a puff of wind." According to this theory, the cavity of the 
chest above the point at which oegophony is audible, must be occupied by air 
alone, which we know is not the case. There is no reason to doubt the correct- 
ness of the ordinary explanation, to wit: the existence of a thin stratum of 
fluid, between the lung and the ribs opposite the larger bronchial tubes, which 
is thrown into vibration by the voice. As the lung is thrust away from the 



166 



Bibliographical Notices. 



[July, 



ribs by the accumulating effusion, the stratum grows too thick to assume the 
vibratory action, and oegophony ceases until the decrease of the fluid restores 
the same mechanical relations. The fact that pleurodynia is generally felt 
below and to the outside of the nipple, is well explained by the fact that at this 
point the movement of the ribs in respiration is greatest. 

Allusion is made to the occasional value of the microscope as an aid in diag- 
nosis. " A young lady with some suspicious chest symptoms expectorated sud- 
denly several ounces of a dark-red or chocolate-coloured fluid. This was sus- 
pected to be blood, in part at least. But on examination by the microscope, 
not a single blood-disk could be discovered, but an immense number of epithe- 
lial scales from the mucous membrane of the bronchi, sufficient to give the 
fluid its reddish colour." 

In the opinion of our author, chronic bronchitis is not much under the influ- 
ence of remedies, at least in a variable climate like ours, and he, therefore, 
relies more upon removal to a more genial climate when this is attainable. 
As a substitute for this means he speaks favourably of the respirator, or wire- 
gauze screen, which becomes warmed by the breath, and saves the lungs from 
the direct contact of cold air. The invigoration of the digestive powers he 
justly esteems to be an important element of the cure, and therefore counsels a 
sparing resort to the medicines recommended for this disease, and which very 
generally impair the digestive function. In hooping-cough, Dr. S. is of opinion 
that belladonna is, at best, a palliative: he does not believe that it shortens the 
duration of the disease. Other observers have been more fortunate in its use. 

The chapter on Pneumonia is a very complete picture of this prevalent and 
interesting disease. The author does not think that the difference between in- 
flammatory congestion and simple stasis of blood in the lungs can be defined, 
and he rejects the ordinary test that in inflammation the tissues are softened, 
but are not so in congestion. If this solution be not applicable in every case, 
it certainly is so in the greater number, and is, indeed, the only one that can be 
appealed to. Gangrene of the lungs he is inclined to attribute to a loss of nu- 
trition from obliteration of the arteries, and very seldom to inflammation. The 
former supposition is destitute as yet of any material support, while the latter 
is proved as regards a certain number of cases, and is, therefore, an allowable 
hypothesis for many more. Yet the inflammation in these cases is not sthenic 
and marked by the usual excess of fibrine in the blood. It would appear to be 
subordinated to a depressed state of the system, one incapable of setting up a 
true inflammatory process. Speaking of the influence of cold in the produc- 
tion of pneumonia, the author calls attention to the prolonged action of the 
cause as an important element. A momentary or brief exposure to even a very 
low temperature is far less injurious than the continued operation of this 
agency, especially in conjunction with dampness. A striking fact illustrating 
tAie influence of position in determining the seat of inflammation, is derived 
from observations made at the Maternite in Paris. The nurses of this institu- 
tion place the children on the right side, and carry them on the left arm. " It 
was observed that nearly all the attacks of pneumonia were in the right lung. 
Care being taken to reverse the position of the children, the frequency of the 
disease did not diminish, but its seat was changed to the left lung." The 
author dwells on a very important fact, the tendency of females to exhibit a 
degree of delirium during the active stage of pneumonia very much out of pro- 
portion to the real gravity of the local affection. The fact we say is important, 
because it has doubtless led to an undue amount of bloodletting in many cases, 
singularly ill-prepared to bear the loss. Cold to the head, opiates, and nervine 
stimulants afford speedy relief. The salutary influence of bleeding in sthenic 
pneumonia, as well in mitigating the patient's suffering as in shortening the 
attack, are illustrated by the valuable results contained in Grisolle's treatise, 
which Dr. Swett abundantly confirms. He is also more persuaded of the good 
influence of tartar emetic than of mercury in this disease. 

The subject of pleurisy is well handled. The author dwells particularly on 
the insidious character of the subacute form which sometimes reaches the 
stage of full effusion without seriously attracting the attention. In such cases, 
tiwre is reason to suspect tubercles as the exciting cause. Several examples 



1852.] 



Swett on Diseases of the Chest 



167 



are given in proof of this opinion. Dr. Swett, in speaking of pleurisy in young 
children, is unable to explain the fact that bronchial respiration should some- 
times be heard over the whole lung, even when the effusion is very large. He 
suggests that " in children the respiratory function is very active, and probably 
the lung is less compressible than in the adult." The reason does not appear 
to us very obscure. The walls of the chest being very extensible in children, 
they yield before the effusion, and allow the lung to retain more nearly its 
natural volume. 

The author thinks that the operation of paracentesis should be resorted to in 
chronic pleurisy after proper remedies have been tried in vain, and before the 
vital powers are much exhausted. He lays down the following conditions for 
the operation : 1. When the side is much dilated, the intercostal spaces bulging 
and fluctuating, or when pointing has occurred. 2. When none of the above 
conditions exist, except that the effusion is undiminished by treatment. 3. 
When the effusion, having been partially absorbed, remains stationary. He, 
further, does not regard the probability that an abscess is forming in the lung, 
nor that the patient is tuberculous, as positive contraindications, if other cir- 
cumstances render the operation proper. About two-thirds of the cases which 
fell under his observation terminated successfully, the proportion being greater 
among children than among adults. 

Speaking of the treatment of croup, the author remarks that " so unavailing 
have been the efforts of some of our best practitioners to cure genuine croup 
by antiphlogistic remedies, or by a perturbating treatment, consisting in the 
frequent administration of emetics in conjunction with antiphlogistic remedies, 
that some have thought best to abandon this mode of treatment and to leave the 
case pretty much to the efforts of nature." We should hope that so illogical 
and uncharitable a conclusion were adopted only by very exceptional practition- 
ers. To accept it would argue a strange degree of ignorance of the actual 
results of treatment in pseudo-membranous laryngitis. Even the mere spong- 
ing of the larynx with a strong solution of nitrate of silver were preferable to 
such a' " meditation upon death." Of the method just alluded to, there is, to 
use our author's language, " reason to hope, and some reason to believe" that 
it " may be attended with benefit, especially in cases in which the inflammatory 
action has originally been inconsiderable, or has been subdued by other means." 
In reference to the success of tracheotomy in this disease, the author makes a 
just distinction of cases. Thus, where the asphyxia comes on through the gra- 
dual closure of the air-passages, and the constitution loses at every step of the 
attack a portion of its resisting power, tracheotomy offers a far slighter chance 
of life than when the attack of suffocation rapidly attains its crisis. If it be 
well settled that the operation itself does not involve life, the sooner it is per- 
formed the better, provided the disease proceeds from above downwards, or is 
confined to the larynx and trachea. But unhappily these conditions can only 
be conjectured to exist. 

The chapter on Laryngitis is copious and instructive. Speaking of the 
chronic varieties of the disease, the author expresses the opinion that most 
cases of chronic laryngitis occur in connection with the scrofulous constitution, 
and are aggravated by an impaired state of the general health, dyspepsia, men- 
tal anxiety, and fatigue. "It is common to hear," he remarks, " of the inflam- 
mation spreading from the fauces to the larynx, and so downward to the bron- 
chi, and finally to the lungs, inducing disease of the lungs. The real truth is, 
I think, that, in the majority of instances, the lungs were first affected, and that 
the disease has spread upward to the larynx and to the fauces." ..." The 
influence of dyspepsia, with an impaired state of the general health, in con- 
tinuing, if not in causing the slighter forms of laryngeal disease, is very 
striking. Yet many of these cases are by no means attended by important or- 
ganic changes in the larynx. I am inclined to think that weakness and relax- 
ation of the parts more directly concerned in the production of the voice, is 
often the chief difficulty, and will explain the hoarseness and the sense of ex- 
haustion that frequently follow the exercise of the voice in clergymen ; and 
that the good effects of stimulating applications to the parts, combined with 
rest, is quite as much owing to their increasing the nervous energy, as in 



168 



Bibliographical Notices. 



removing any traces of inflammation that may be supposed to exist." But, in 
some cases, chronic laryngitis succeeds an acute attack of inflammation which 
has been imperfectly cured, and presents tenderness, and a sense of heat and 
constriction in the larynx, dysphagia, hoarseness, slight sibilant respiration, 
with a laryngeal cough, as its principal symptoms. It is in such cases par- 
ticularly that a solution of nitrate of silver " applied to the interior of the 
larynx by means of the whalebone and sponge, as first recommended by Trous- 
seau and Bellocq, may be permanently useful." But the most common and 
important form of chronic laryngeal inflammation is that alluded to in the be- 
ginning of this paragraph. It is so well characterized by the author that we 
quote his remarks, and commend them to those who have been misled by 
representations which seem to have been put into currency from other motives 
than a love of truth. 

" A second class of cases, far more numerous, and in part at least dependent 
on a constitutional cause, the scrofulous diathesis, are much more insidious in 
their development, and much more difficult of cure. The subjects of this form 
of this disease are pale and delicate persons, who inherit a feeble constitution. 
If a careful inquiry be made, it will frequently be noticed that such persons 
have, for a long time, before any distinct laryngeal disease has manifested itself, 
been subject to an irritation of the throat, indicated by a more or less frequent 
desire to clear it of mucus, and a tendency to slight hoarseness and weakness in 
the chest, after singing, or other exercise of the voice. In clergymen particular- 
ly, in whom this form of disease is very frequent, you will see the best type of its 
development. An examination of the throat discovers the parts somewhat con- 
gested, the tonsils slightly enlarged, the posterior fauces presenting red elevated 
patches of thickened mucous membrane, with increased mucous secretion. 
Yet, with these evidences of chronic inflammation, the parts are relaxed, the 
vessels are large and often arborescent, the uvula swollen, oedematous, and 
flabby, and capable of being drawn out to twice its natural length by moderate 
traction with the forceps. The degree of hoarseness presents every possible 
variety, while the sibilant respiration is rarely met with. The pain in swallow- 
ing, as well as the tenderness over the larynx, is seldom marked. The sensa- 
tion in the larynx is like the aching from fatigue. Such cases are often much 
relieved by rest, by local applications, like the nitrate of silver; but they are 
very apt to return again, especially under the influence of unfavourable excit- 
ing causes, as undue exercise of the voice, fatigue, anxiety, and other depress- 
ing influences. This form of the disease cannot properly be separated from the 
constitution that is almost uniformly found to attend it, and the chances of per- 
manent benefit are intimately connected with constitutional remedies which 
improve and invigorate the general health, such as a sea-voyage, travelling, 
freedom from fatiguing and anxious occupation, and the use of a general tonic 
course. Such patients are often encouraged by even a slight improvement in 
their condition. They even think that they are almost or quite cured, until a 
relapse teaches them that a perfect recovery is not so easily attained. 

" In these cases, you may discover no pulmonary disease. There may even 
be no cough, but only a hawking from the throat of mucus, although cough also 
is frequently present. Yet if, in time, the lungs do become implicated, which 
is very probable, and cavities form in them, then the laryngeal symptoms be- 
come aggravated by the supervention of ulceration. This is not, however, 
always the case, for the laryngeal disease, even if ulceration be present, may 
be masked to a certain extent by the pulmonary complication. Besides, much 
will depend upon the seat of the ulcerations. Those which attack the epiglot- 
tis give the most trouble, from the dysphagia they induce, while, if the vocal 
chords are attacked, the hoarseness may be much and permanently increased." 

A case of simple aphonia, occurring in a person of a nervous temperament, 
was successfully treated by the author with strychnia. 

The coexistence of emphysema of the lungs and tubercles renders detection of 
the latter difficult. The author would rely upon the rational symptoms, such 
as progressive emaciation, acceleration of the pulse, hectic fever, and hemoptysis, 
to form an opinion ; if, in addition to these, the respiration is simply feeble at 
the summit of the lung, but with increased vocal resonance, the existence of 



1852.] 



Swett on Diseases of the Chest. 



169 



tubercles is probable. A common source of error is thus described and pro- 
vided against: "A young person, perhaps, of rather delicate constitution, 
notices habitually a slight degree of dyspnoea, and a trifling cough. The chest 
is examined, and a slight degree of dulness on percussion is detected beneath 
one of the clavicles. This may lead to a suspicion of tubercles. But this dul- 
ness is apparent, not real. It exists by comparison only, because a slight degree 
of emphysema in the opposite lung has increased somewhat the natural resonance 
on percussion. If, in this case, a slight fulness of the walls of the chest should 
happen to exist about the clavicle where the emphysema is seated, then the 
opposite space might not only sound dull, but seem depressed; and thus a new 
suspicion of tubercles might arise. But where the apparent dulness and depres- 
sion exist, the respiratory murmur is distinct and natural. On the emphysema- 
tous side it is feeble." 

As in other works on diseases of the chest, consumption occupies a large 
space in the one before us; it holds a mournful pre-eminence among the ills 
which flesh inherits, and one which the author does not think likely to be lost 
even by the apparently flattering success of the new means directed against it. 
In considering the influence of climate as originating and developing this dis- 
ease, he lays a good deal of stress upon the mortality produced by it among the 
soldiers of the British and American armies, inferring that a warm climate is 
more favourable to its production than a cold one. We think that, as all of the 
statistics relate to persons, natives of a cold climate, who have been transferred 
to a warmer latitude, the results afford no criterion forjudging of the influence 
of temperature as a cause of phthisis. Unquestionably this disease is of less 
frequent occurrence in warm than in the so-called temperate climates. The 
question, then, whether a person inclined to consumption would profit by re- 
sorting to a tropical climate can only be answered by the fruits of direct obser- 
vation, by ascertaining how far such a change of residence has actually bene- 
fited those who have sought by its means to ward off a threatened attack, or to 
stay the progress of the already developed disease. Accurate data are wanting 
to solve this question. 

It is often asserted that the use of ardent spirits tends to prevent the develop- 
ment of phthisis. The following fact bears upon this question. Two medical 
gentlemen, the author states, who are attached to the public Dead House, of 
New York, in which bodies are deposited which are found in the streets, or 
without friends, discovered, in about seventy post-mortem examinations of those 
who had died of the most confirmed and aggravated intemperance, not a single 
case of tuberculous lungs. Perhaps it may be objected, persons of a delicate 
constitution, and who are predisposed to phthisis, have less tendency than the 
robust towards those associations and habits which induce intemperance, and 
that they also feel less craving for artificial stimulus. However this may be, 
the fact adduced by Dr. Swett conforms to general experience, for consumption 
has no place in the swollen catalogue of mischiefs attributed by medical writers 
on intemperance to this destructive vice. 

The author is of opinion that hemorrhage from the lungs does not act unfa- 
vourably on the general progress of consumption. On the contrary, he believes 
that it rather promises a long course to the disease, particularly if it assume the 
passive form. The most protracted case of phthisis he ever knew, and which 
lasted thirty-five years, was marked by occasional returns of, sometimes, very 
copious hemorrhage. These views correspond with those expressed by Dr. 
Walshe. 

A very important principle is involved in the caution which the author gives 
against inferring the existence of actual phthisis from signs of solidification at 
the summit of the lung. When a cure of tubercle in this situation takes place 
the pulmonary tissue is left condensed, and will therefore furnish the same 
physical signs as if a mass of tubercle were situated there ; there may even be 
signs of a cavity remaining after the thorough removal of tubercle from the 
lung. Hence the respiration may be feeble, harsh, jerking, bronchial even, and 
the percussion decidedly dull, without any tubercle to produce these sounds. 
The whole history of the patient, and his general symptoms form in such cases 
an essential and indispensable element of the diagnosis. 



170 



Bibliographical Notices. 



[July, 



To the question, is consumption curable? Dr. Swett returns an affirmative 
answer. Not, however, in many cases of strongly-marked phthisis, although 
instances of marvellous recovery do occasionally take place. In illustration of 
the latter statement the history of a patient is related, who, to all appearance, 
was so far gone in consumption, with a large and well-marked abscess under 
the clavicle, that he was daily expected to die. Yet in the course of two months 
afterwards he had grown so stout as hardly to be recognized. The author states 
that during the last fifteen years he has known a number of patients who at- 
tained the enjoyment of good though not perfect health, after having had evi- 
dences of phthisis, and sometimes in an advanced stage. During the same 
period he has been struck with the number of cases in which patients, dying of 
other diseases, have presented traces of phthisis that had been cured; and, on 
the whole, concludes that the common expression, "the patient could not have 
had phthisis because he recovered," will cease to be believed. As to the means 
which are fitted to secure, or at least promote, the cure of consumption, he fur- 
nishes nothing new. The influences of relaxation, food, climate, &c, are in his 
opinion the capital ones, and not at all to be subordinated to the various specifics 
which from time to time have been vaunted. Even cod-liver oil is destined, in 
his opinion, to share the same fate as antimony, digitalis, iodine, &c. " It has 
not," he asserts, " any specific influence in phthisis. It has not, in my expe- 
rience, performed any wonderful cures. I do not, however, mean to deny its 
usefulness in this disease. It certainly sometimes appears to diminish the 
emaciation, to improve the appetite. It is good nourishment, nothing more; 
and I think it probable that other kinds of oil, equally well prepared, may exert 
the same beneficial influence." This judgment will hardly stand against the 
recorded proofs of the efficacy of cod-liver oil. We speak not of assertions 
merely, which cost nothing to make as positive as may be required, but of evi- 
dence which, whether we consider the character of the witnesses for skill and 
probity, their number, their agreement, or the material proofs of their statements, 
presents a demonstration which scepticism only could resist. Doubtless the 
truth is exaggerated ; doubtless, also, direct falsehood has been published, but 
enough solid and incontrovertible truth remains to establish for cod-liver oil a 
power over consumption possessed by no other agent whatever. 

The author condemns emphatically and with great justice the practice of 
employing medicines in consumption which do not compensate by their useful- 
ness for the mischief which they do to the digestive function. In this category 
may be included digitalis, venesection, and the whole catalogue of expectorants. 
Anything of this description, beyond what is requisite for palliating the cough, 
is injurious by impairing digestion ; even opium, that precious drug, should be 
used with an avaricious hand, and carefully proportioned to the actual needs 
of the patient. Of issues on the chest and other permanent forms of counter- 
irritation, the opinion of the author is that they are useless with respect to the 
primar}- disease, but may relieve the secondary inflammations which sometimes 
accompany it. He thinks, also, that liniments, applications containing oil and 
plasters, are objectionable as tending to interrupt the cutaneous exhalation. 
This is evidently a theoretical objection to the applications mentioned, and we 
have, on the other hand, the practical fact that the cough and sputa are dimin- 
ished, and the comfort of the patient increased by them. The best applica- 
tion to the chest is, in the author's opinion, water either cold or warm, accord- 
ing to the strength of the patient. We think that much caution is necessary 
here. Consumptive patients are exceedingly chilly, and may have the thoracic 
symptoms aggravated by water applied almost at the temperature of the body. 
The evaporation of the fluid, during the moment it remains upon the skin, is 
sometimes sufficient to produce this effect. Dry friction with a coarse towel is 
a safer and a very efficient stimulant, and a revulsive which may be used where 
water is inadmissible. The respirator, or screen of wire gauze, intended to 
moderate the action of cold air upon the lungs, is here again favourably spoken 
of by the author. It is an excellent invention, for it enables patients to breathe 
the fresh air and take the exercise so essential to maintaining their vigour during 
the long and severe winters of our climate. 

The chapter on Cancer in the Lungs is, perhaps, the most complete in the 



1852.] 



Swett on Diseases of the Chest. 



171 



work before us. It appears to have been based upon an analysis of original 
and selected cases of the disease. After a clear and succinct account of the 
general anatomy of cancer, the author states that encephaloid is the most com- 
mon variety affecting the lungs. Thus, of twenty cases, sixteen belonged to this 
form, three of encephaloid and scirrhus united, and one of scirrhus and colloid. 

One of these tumours, described by Dr. S., weighed eleven and a half pounds. 
Five times in twenty the tumour originated in the posterior, and once in the 
anterior mediastinum. In twenty cases the amount of deposit was sufficient 
to have produced physical signs of disease, ten times over the right and six 
times over the left lung. The disease may terminate fatally in two months 
after the first development of its symptoms ; it may continue for four years ; its 
mean duration being between thirteen and fourteen months. The age of the 
patients in the cases furnishing this summary varied between twenty-three and 
seventy-two years, and five of them only were females. 

The author divides cases of cancer of the chest into two classes, those in 
which the disease originates in the lung, and those in which the mediastinum 
is its original and principal seat. The symptoms of the latter are chiefly such 
as are due to pressure. Neither form has characteristic symptoms, none, at 
least, until an advanced stage of the disease ; and then, besides the general 
phenomena of consumption, oedema of the face and extremities, enlargement 
of the superficial veins of the trunk, and the characteristic straw colour of the 
skin, give certainty to the diagnosis. The affected side of the chest is generally 
contracted. Neuralgia of the thoracic and brachial nerves is met with in some 
cases. Dr. Swett does not regard the straw colour of the skin as diagnostic of 
cancer, but merely as denoting anemia ; for, in his analysis of cases, this symp- 
tom appears to be connected with hemoptysis; and he remarks, further, that 
this complexion is quite as characteristic of fibrous tumours of the uterus with 
hemorrhage, as it is of any form of cancer. The differential diagnosis of 
cancer of the lung will best be understood by the following extracts: — 

" The diseases with which cancer of the lung is most apt to be confounded, 
are tuberculous phthisis, empyema, and aneurism of the thoracic aorta. In 
phthisis, the disease often commences with nearly the same symptoms, and 
progresses in a similar manner ; and even the physical signs, as in one of the 
cases that occurred to myself, may be quite analogous. Yet in most cases of 
cancer, there are some anomalous symptoms which are not met with in phthisis. 
Thus, in the case to which I have alluded, there was severe neuralgic pain 
extending down the arm, which at once made me doubt the existence of 
phthisis. The pulse was also quite natural in frequency, which could certainly 
not be expected in a case of phthisis so far advanced, and there was no hectic. 
The absence of hectic symptoms and a tranquil pulse seem to be rather striking 
characteristics of cancer before the period of softening; a condition which, pro- 
bably, does not often occur until a late period of the disease. A leading fact 
in the history of tuberculous disease is the great uniformity of its seat at the 
summit of the lung, and its tendency to pass to the formation of cavities. 
Neither of these facts is true in cancer. Again, tuberculous disease in its 
progress most frequently affects both lungs so as to be recognized by the phy- 
sical signs. This is not the case with cancer. The physical signs are seldom 
detected in more than one lung. Again, the symptoms induced by pressure 
upon the veins are not observed in phthisis, as they, not unfrequently, are in 
cancer of the lung. (Edema of the upper regions of the body, enlargement of 
the superficial veins, are not likely to occur in phthisis. Cancerous tumours, 
when developed in other organs so as to be felt externally, are usually larger 
than those of a tuberculous nature. In empyema, the affected side of the chest 
is usually dilated; there is alwa} 7 s extensive dulness on percussion, and absence 
of respiratory murmur, unless at the apex and at the root of the lung. In 
cancer of the mediastinum, precisely the same physical signs may exist, and in 
both diseases you may notice an oedema of the upper portions of the body and 
enlargement of the superficial veins. In the remarkable case of mediastinal 
tumour that I have stated to you, the only physical sign that might have led to 
the suspicion that the disease was not a collection of fluid in the chest was, 
that the dulness, although universal, was yet most marked under the clavicle 



172 



Bibliographical Notices. 



of the affected side. This would not readily happen in empyema; the sub- 
clavicular portion would, probably, sound clearer on percussion than other 
portions of the affected side. 

"In cancer of the substance of the lung, the affected side is usually con- 
tracted and very dull, and a bronchial respiration is heard over it. This cha- 
racter of the percussion and of the auscultation is sometimes met with in 
empyema, but it is rare. You may remember a case to which I alluded when 
speaking of empyema, in which a bronchial respiration existed all over the 
affected lung, with universal dulness on percussion; and which was found, 
after death, to be empyema with ancient adhesion of the lung to the diaphragm. 
But in this case the side was dilated, which would not have happened, probably, 
in cancer of the lung ; although in empyema the side is not necessarily dilated. 
I have seen it contracted, even with a considerable effusion of pus in the 
chest. 

" Cancer of the lung may be confounded with aneurism of the aorta, or with 
valvular disease of the heart. If a cancerous mass, too small to produce any 
external tumour, is infiltrated around the origin of the great vessels of the 
heart and compresses them, the physical conditions of a permanent organic 
bellows murmur are produced. How could you distinguish this case from val- 
vular disease of the heart? Not by the sign I have mentioned. But, perhaps, 
other circumstances might exist. The heart is not enlarged, perhaps, as it 
would probably be in valvular disease. So in the attempt to diagnosticate a 
tumour caused by a cancerous mass from an aneurism of the thoracic aorta. 
How could you do this? Both diseases are tumours, compressing, irritating 
the organs in the chest. But an aneurism of the aorta has certain favourite 
seats in the chest, in front, about the right third rib, at the top of the sternum, 
above the clavicle. These are not the favourite seats of cancerous tumours. 
Again, a bellows murmur remote from the heart, a thrill, and when it presents 
externally, an expansive pulsation, belong to aneurism, rather than to a can- 
cerous tumour. Finally, in all suspicious cases, be careful and examine other 
portions of the body — the abdomen, the subcutaneous organs, and, perhaps, 
you may discover a tumour, or many tumours, which will aid you materially 
in the diagnosis." 

In the division of the work relating to diseases of the heart, the author de- 
votes two lectures to an account of the action of the organ, and the signs 
furnished by.it in disease. He follows very nearly the exposition of these 
which was taught by Hope, and does not appear to have paid much attention 
to the nicer distinctions which recent observation has established. The impulse 
of the heart is ascribed exclusively to the systole of the ventricles ; but, as 
usual, the phenomena of* the particular cases refute this theory. Thus it is 
stated that, according to Dr. Taylor, the friction sound, when double, is most 
distinct with the ventricular diastole, and that when single it usually accom- 
panies the diastole ; a state of things wholly irreconcilable with the theory of 
the impulse being caused by the systole of the ventricle. Again (p. 502), a 
case is related in which there were two hundred and eight pulsations of the 
heart per minute, for ninety-six of the radial artery, which would be impos- 
sible, except on the supposition that the former pulsations occurred during the 
diastole of the ventricle, or on that of the vessels being almost empty of blood. 
But here the latter cause did not exist. 

The lectures on Pericarditis and Endocarditis present a full and clear history 
of these affections ; but the limits of this notice forbid our entering into par- 
ticulars. Some remarks on the treatment of the former disease, however, 
deserve notice. Every one must have remarked the extremely slow progress 
of absorption in some cases of pericardial effusion. This sometimes appears to 
depend upon the patient's feeble constitution, or upon the adoption of too 
active a treatment at the commencement of the attack of rheumatism, or what- 
ever affection gave rise to the pericarditis. In these cases the author calls 
attention to the necessity of abandoning all antiphlogistic remedies, and 
resorting at once to a nutritious diet, with tonics, such as the compounds of 
iodine and iron, and securing rest by opiates. There are mixed cases, too, in 
which a tonic treatment should be added to a cautious mercurial course ; and 



1852.] 



Swett on Diseases of the Chest. 



173 



chronic cases, which demand iodine and mercury, along with diuretics and 
blisters. In endocardial inflammation, or what passes for such in the course 
of acute articular rheumatism, the author adopts the strenuous advice of Dr. 
Latham, to commence the mercurial treatment early in the disease, and to 
pursue it actively, and he adds that his own experience confirms the observa- 
tions of the eminent author of this suggestion. 

Under the head of Enlargement of the Heart, Dr. Swett unites the considera- 
tion of hypertrophy and dilatation, because, as he remarks, these two conditions 
are generally united. In an elementary work, it would have been more intel- 
ligible to treat of them separately. The reader would then have formed a 
clearer notion of what symptoms are due to each element of the combined disease 
which is most frequently met with in practice. The account of them is, for the 
most part, clear and consistent. The chapter on valvular disease presents a 
very faithful history of the symptoms and lesions of this class of affections, 
though we think that an occasional error is committed by explaining the phe- 
nomena according to the prevalent theory ; and that numerous points are 
passed more lightly over than they would have been in a course of lectures 
written at the present time. The progress of the last ten years has completed 
or rectified many doctrines. Such, for instance, is that of cyanosis, which Dr. 
Swett explains by the now untenable theory of the admixture of the venous 
with the arterial blood. 

Functional disturbances of the heart are described, as well as the causes 
which produce them by debilitating the nervous system. Several interesting 
cases in which the affection arose from venereal excesses are related, and some 
which belong rather to the category of angina pectoris. Inflammation, indura- 
tion, softening, fatness, rupture, atrophy, displacements, malformations, and 
polypi of the heart, are briefly but clearly discussed ; the last subject particu- 
larly is dwelt upon as an accidental cause of death which it is hardly possible 
to foresee or to provide against. In the two concluding lectures the author pre- 
sents a history of aneurism of the heart and great vessels, which contains all 
that inessential to an understanding of the subject, and is illustrated by several 
interesting cases. In one of these the rupture of the aneurism took place in 
the spinal canal, inducing sudden paraplegia; in another, an aneurism of one 
of the coronary arteries, about the size of a pigeon's egg, had ruptured into the 
pericardial sac. The case was that of a young lady who had just been dressing 
herself for a ball. In descending the stairs, from her chamber, she died sud- 
denly. The following statistics of aneurism are interesting : — 

" In 40 cases of aneurism of the ascending aorta, 19 were ruptured ; 16 were 
of the false variety ; one an aneurism by dilatation ; and in two cases their 
character was doubtful. Of these — 7 ruptured the pericardium ; 2 the right 
ventricle ; 2 the right auricle ; 2 the vena cava superior ; 1 the pulmonary 
artery; 1 the oesophagus ; 2 the right pleura; 1 the left pleura; 1 the right 
lung. 

"In 31 cases of aneurism of the arch, 20 were ruptured. Of these — 16 were 
cases of the false aneurism ; 3 of the aneurism by dilatation ; in one case the 
character was doubtful. Of these — 6 ruptured the trachea; 3 the oesophagus; 
3 the left pleura; 3 the pericardium ; 1 the left bronchus; 1 the left lung; 1 
the pulmonary artery ; 1 the posterior mediastinum ; 1 externally. 

"In 16 cases of aneurism of the descending thoracic aorta, there were 20 rup- 
tures : 15 were the false aneurism ; 1 of the aneurism by dilatation. Of these 
— 5 were ruptures of the left pleura ; 3 of the left bronchus ; 3 of the oesophagus ; 
2 of the left lung ; 2 of the trachea ; 2 of the right lung ; 2 of the posterior 
mediastinum ; 1 of the pericardium." 

When describing aneurism of the arteria innominata, the author alludes to 
what he styles "the bold and brilliant operation of Dr. Mott, for the cure of 
this aneurism," a strange epithet, as it strikes us, when applied by a pathologist 
of Dr. Swett' s attainments. 

In conclusion, mention is made of stricture of the aorta which the author 
regards in the light of a pathological curiosity. He refers only to two cases, of 
which one occurred to Mr. Nixon, of Dublin, and the other to Dr. Clark, of New 
York. In both cases, aneurism was supposed to exist. The most complete 
No. XL VII. — July, 1852. 12 



174 



Bibliographical Notices. 



[July, 



account of this subject is contained in the Inaugural Thesis of Dr. Barth, of 
Paris, published in 1837, and is founded on an analysis of twenty-four cases, of 
which one was original. .The diagnostic symptoms are chiefly the following: 
coldness, weakness, and numbness of the lower limbs, without pain in the spine 
or symptoms of apoplexy, and then the appearance of ecchyrnosis on the extre- 
mities. If these signs, or some of them, fail, there may still be observed strong 
pulsations of the arteries of the upper part of the body,, and comparatively feeble 
ones of those supplying the lower limbs, unwonted force of the intercostal arte- 
ries, and sometimes a difference like that just noticed in the pulsations of the 
aorta itself above and below the point of stricture. In Dr. Clark's case, as in 
others, a loud sawing sound was heard beyond the seat of the disease, but on 
the cardiac side of it not at all. 

The foregoing are the principal points in the work before us which seemed 
to call for criticism, or which make some addition to the knowledge which was 
already possessed concerning thoracic diseases. The work of Dr. Swett, taken 
as a whole, will be found useful by the learner, to whom it seems particularly 
addressed, because it presents its subject in a plain, intelligible, and accurate 
manner. The practitioner will value the illustrations drawn from the author's 
personal experience, and appreciate the simplicity and good sense which mark 
its precepts. A. S. 



Art. XYII. — Reports of American Institutions for the Insane. 

1. Of the New York State Lunatic Asylum, for 1849 and 1850. 

2. Of the New York City Asylum (Blackwell's Island), for 1849 and 1850. 

3. Of the New Jersey State Asylum, for 1849 and 1850. 

4. Of the Pennsylvania Hospital for the Insane, for 1849 and 1850. 

5. Of the Frankford Asylum, for 1848, 1849, and 1850. 

6. Of the Maryland Hospital, for 1846, 1847, 1848, 1849, and 1850. 

1. Dr. Brigham, the late distinguished superintendent of the New York State 
Asylum, died in the summer of 1849, and his place, during the remainder of the 
year, was filled by his principal assistant, Dr. George Cook, by whom the report 
before us was written. 

Men. Women. Total. 
Patients at the beginning of the year . . 241 254 495 
Admitted in the course of the year . . . 192 170 362 

Whole number 433 424 857 

Discharged 207 201 408 

Remaining at the end of the year . . .226 223 449 
Of those discharged there were cured . .113 90 203 
Died 35 34 69 

" During the past summer," says the report, " while the epidemic cholera 
pervaded a large portion of our country, we, through the kindness of an over- 
ruling Providence, were spared from its ravages ; and, with the exception of 
some cases of dysentery, in the months of August and September, the general 
health of our patients was good. But in the month of December last (1848), the 
asylum was visited by the smallpox, which continued to prevail amongst us for 
several weeks, and in a number of cases proved fatal. No person who came here 
had the disease at the time of admission, or, as far as we could learn, had come 
from a section of the country where it was prevalent. It made its appearance in 
the female division of the asylum, and the first case occurred in a patient who 
had been here about seven months." The first, second, third, and fourth cases 
were very mild ; the fifth, in a patient who had been at the asylum several 
months, confluent and severe. When attacked, the patients were removed to 
the infirmary. 

" Of four hundred and ninety patients who were in the house at the time, 
and who were more or less exposed, forty-eight took the disease ; viz., twelve 



1852.] 



American Insane Hospital Reports. 



175 



men and thirty-six women. Thirty-three had it in a mild form ; of these, six 
were men and twenty-seven women. Fifteen had the confluent form, of whom 
six were men and nine women. Fourteen died in the course of the disease, or 
soon after its termination ; viz., five men and nine women, of whom eleven 
died of the disease, and, in the other three, death was only perhaps a little 
hastened by it." Besides the above, eight attendants had the disease, two of 
whom died. 

The remaining fifty-five deaths were caused as follows : Dysentery 14, menin- 
gitis 7, consumption 6, exhaustion following excitement 5, general paralysis 4, 
epilepsy 3, marasmus 2, diarrhoea 2, pneumonitis 2, ascites 1, hydrothorax 1, 
suicide 1, puerperal fever 1, " disease of spinal cord" 1, erysipelas 1, apoplexy 
1, " serous diarrhoea" 1, old age 1, " peritoneal inflammation from perforation 
of the intestines" 1. 

The general system of moral treatment introduced by Dr. Brigham is still 
pursued. The tailor's shop appears to be no unimportant item in this system, 
as the report contains a list of no less than four thousand six hundred and four 
garments and articles of household furniture made in it during the year. 

The officers of this institution have, for several years, taken particular pains 
to ascertain the number of suicides that occur within the State of New York. 
They think that " nearly all" are included in their tables, the totals of which 
are — for 1845, seventy-four ; 1846, sixty-four ; 1847, one hundred and six: 1848, 
eighty - eight ; and for 1849, sixty-two. 

The report for 1850 is the first issued by Dr. N. D. Benedict, the successor 
of Dr. Brigham. It is elaborate, and ably written. 



Patients at the beginning of the year 
Admitted in the course of the year 
Whole number .... 

Discharged 

Remaining at the end of the year 
Of those discharged, there were cured 
Died 



Men. Women. Total. 

226 223 449 

185 182 367 

411 405 816 

209 178 387 

202 227 429 

94 77 171 

34 17 51 



Causes of death. — Chronic mania 12, acute mania 2, dysentery 13, general 
paralysis 3, erysipelas 4, pleuritis 2, phthisis pulmonalis 2, diarrhoea 2, opera- 
tion for strangulated hernia, acute gastritis, typhus fever, acute dementia, 
aneurism of aorta, phagedeena, ascites, metro-peritonitis, strangulation, suicide, 
1 each. 

Of the deaths from chronic mania the report says : " These cases presented 
no evidences of organic disease ; no inflammation, or results of inflammation, 
in any tissue or organ. For months before their dissolution the capillary circu- 
lation became extremely feeble, the secretions imperfect, the elaboration and 
appropriation of food defective, and consequent emaciation ensued. The 
whole train of morbid phenomena being referable to insanity, it seems proper 
to report them as dying of mania rather than of marasmus." We suspect, 
however, that such cases are, in most asylums, reported as deaths from maras- 
mus. 

" Thirteen died of dysentery, though it was at no time epidemic in the institu- 
tion. We include, under this head, a form of disease very unlike dysentery of 
private practice and of general hospitals, but which we believe is very common in 
asylums, and which we do not recollect to have seen called by any other name. 
In occurs in chronic cases whose powers of life have long been gradually 
sinking, and, in recent cases, who have become much exhausted by protracted 
excitement. Without premonitory symptoms, or exposure to known exciting 
causes, the patient is suddenly seized, and generally in the night, with bloody 
discharges, scanty and gelatinous, or, more frequently, copious and serous, 
with no heat of skin or abdomen, nOr pain or thirst, or loss of appetite or 
strength. Death supervenes a few days after the attack. We have perceived 
but little benefit from remedies in this form of disease, the treatment for ordi- 
nary dysentery proving entirely nugatory." 

There were twenty-three cases of erysipelas in the course of the year, mostly 



176 



Bibliographical Notices. 



in the cold months, when the air of the halls was the most impure. " It is 
said of one of the New England hospitals, before infested with erysipelas, that, 
after the introduction of a system of forced ventilation, this formidable disease 
entirely disappeared." 

One of the cures reported was ihat of a man who had been insane upwards 
of six years, had been several years in the asylum, and long considered as 
demented and incurable. " He would stand for hours in strange postures, 
apparently without thought or feeling. Gradually, he began to take notice of 
things around him, and to exercise. He resumed his trade, that of a tailor, 
and at length acquired his former dexterity and skill." This case furnishes 
another proof, not only of the importance of perseverance in the treatment of 
the insane, but also of the singularity of this wonderful and mysterious disease. 
By " perseverance in treatment" we mean the keeping of the chronic insane at 
institutions where the circumstances of their position furnish the greatest aid 
to a spontaneous or natural cure ; for we presume that, in this case, medical 
treatment had long been abandoned. The case reminds us of one which once 
came under our observation. A lunatic had been under curative treatment 
until the hope of restoration was relinquished. He was pronounced incurable ; 
a commission of lunacy was immediately appointed, his case legally investi- 
gated, and he was put under guardianship. Within three weeks from that time 
he was perfectly well, and soon returned to his employment as clerk in a large 
mercantile establishment. 

In the treatment of acute mania, with violence, raving, and consequent ex- 
haustion, Dr. B. employs seclusion, hot baths with cold applications to the 
head, and free evacuation of the bowels. " In no case," says he, " have we 
found local or general bleedings admissible ; but, on the contrary, nutritious diet 
and brandy-punch are generally demanded." 

The physician by force, in Moliere's " Medecin Malgre' Lui," speaks of the 
stomach as being situated upon the right side, and the liver upon the left. An 
interlocutor seems puzzled by this asserted position of the viscera, and men- 
tions his impression that the stomach is on the left side and the liver on the 
right. Hereupon the physician by force acknowledges that, formerly, such was 
their position, but very sagely adds, " nous autres medecins, nous avons change 
tout cela." With much more truth may it be asserted, in regard to the treat- 
ment of acute mania, as recommended by Rush, and as generally practised in 
this country until within a comparatively few years, " nous avons change tout 
cela." This change has taken place, not at the Utica Asylum alone, but at all, 
or nearly all, the institutions for the insane in the United States. 

" Of moral, or, perhaps more correctly, immoral insanity," says the report, 
"nine cases have been under our care, two of whom have been admitted within 
the last year. These cases present the various forms of derangement, from the 
mere rascally little sinner (two were lads) up to the most aggravated form of 
the genuine disease. We have an idea that a remedy, not much known to 
modern science, but in vogue in the days of Solomon, commenced early and 
faithfully persevered with, would have been eminently successful in preventing 
the development of the disease, or, at least, arrested its progress before its full 
establishment. One of our patients is the exact counterpart, if not the iden- 
tical fellow seen by Mr. George Combe, in the Dublin Lunatic Asylum, who 
exhibits a total want of moral feeling and principle, yet possesses intelligence, 
ingenuity, and plausibility. He has been a scourge to his family from childhood ; 
was sent to the army to get rid of him, from which he was turned out as an 
incorrigible villain, always fighting and getting drunk, for which he was re- 
repeatedly flogged. By seclusion, he becomes so savage as to render the task 
of entering his room and supplying his wants by no means enviable ; and 
when at large he often assaults those around him. His chief employments are 
eating and fighting, and although he is constantly endeavouring to ' get out of 
these barracks,' he seems to have no particular object in view but the more free 
indulgence of these propensities. In all but this one case, moral treatment 
alone has accomplished our object; but on him little moral influence can be 
exerted. By the aid of nauseating remedies and purgatives, frequently ad- 



1852.] 



American Insane Hospital Reports. 



177 



ministered, we are enabled, in some degree, to control him. Blisters and setons 
to the back of his neck are now being tried." 

The physicians to insane hospitals generally acknowledge their tables of 
the " causes of insanity" to be comparatively valueless. That they are so, we 
have a striking proof in the report before us. Of the two thousand three hun- 
dred and seventy-six patients admitted previously to 1849, only nineteen, or four- 
jifths of one per cent, are reported as having originated from masturbation ; 
while of three hundred and sixty-seven, received in the course of the year men- 
tioned, fifty-three, or more than fourteen per cent, are attributed to that cause. 
Now, no reasonable man can believe that both of these statistical items can 
be true. Whence is the error? In the fact, undoubtedly, that they were 
reported, the former by one physician, and the latter by another ; — by two men 
who, although they may have been equal in talent, learning, and skill, may 
have favoured different theories ; or the one may have been somewhat more 
thorough in his investigations than the other. 

" Frequently," writes Dr. B., " the patient himself can give the most satis- 
factory cause of his insanity, and often the very opposite to that attributed 
by his friends. This is especially true of masturbators, whose insanity is 
looked upon by friends as caused by ' religious anxiety/ because the first 
evidence of it noticed was an extraordinary anxiety about their salvation; an 
inordinate fear of future punishment; or abandoning all occupation but that 
of reading; or holding a Bible as if reading; or praying; or mumbling inco- 
herent sentences, in an attitude of prayer, at improper times and places; or 
4 trying to tell his experience' in a religious meeting ; or joining in and going 
to great lengths in the excitement of protracted religious meetings, or in such 
like acts. Another class, frequently placed under the head of ' religious 
anxiety/ are religious monomaniacs, whose insanity is undoubtedly referable 
to dyspepsia, habitual indigestion, and constipation, and the injudicious use of 
remedies for these diseases." 

In the treatment of masturbation, " we rely mainly on mechanical restraint 
and aphrodisiac medicines. The combination we prefer is that of conium, 
camphor, and belladonna ; and we think we have indubitable evidence of its 
power. We sometimes prescribe blisters and cold baths with advantage." 

Although we have exceeded our usual limits in the notice of this report, 
we cannot leave it without laying before our readers the following extract: — 

" Of the 816 patients in the institution, during the past year, the suicidal 
propensity existed in 66, 22 males and 44 females. There were 28 — 21 females 
and 7 males — in the house at one time. In 20 of these 21 females the pro- 
pensity was intense. To have at one time under care twenty-eight persons bent 
upon destroying themselves, is a burden which they alone know who bear it, 
increased by the necessity of carrying, at all times, amid surrounding sadness, 
a cheerful countenance over a heavy heart. The successful attempt at self- 
destruction, before reported, was made on the 12th of July, by a female patient 
of our most intelligent class. Her melancholy end became known to her com- 
panions, with whom she was a favourite, and, on the following day, two other 
patients on the same hall were overheard devising a plan for their own death. 
About this time, the suicidal propensity prevailed extensively, and seemed to 
be epidemic. There were admitted, during the month of July, the large num- 
ber of forty-four patients, from different portions of the State, nineteen of whom 
were suicidal. Several of these had attempted suicide immediately previous 
to admission. Two patients, who had long been in the house, and never exhibited 
suicidal propensities, attempted it during the month (on the 13th), though they 
had no knowledge of the violent death thai had occurred in another portion of the 
building. On the 17th, a patient, believed to be entirely ignorant of all that 
had occurred previously, attempted strangulation, and continued to repeat the 
attempt until restrained by mechanical means. On the 20th, a patient tried 
to open a vein in her neck ; and, on the 22d, another, who knew of the suicide, 
and was no doubt influenced by it, attempted her destruction. 

" From the 14th of July, fourteen attempts were made by eight different per- 
sons; and twelve others, in whom the propensity was strong, required constant 
observation. The suicidal epidemic prevailed from the 12th to the end of 



187 


250 


437 


229 


230 


459 


416 


480 


896 


145 


138 


283 


85 


127 


212 


186 


215 


401 






172 



178 Bibliographical Notices. [July? 

July ; after which time it gradually subsided, and left the minds of most of 
the patients." 

The whole number of patients admitted, since the opening of the 

asylum, is, 2743 

Of whom there have been discharged cured .... 1188 
; v Died , " . . . . V. 320 . 

Men. Women. Total, 

2. The number of patients at the Asylum on 

Blackwell's Island, New York, January 1, 

1849, was, 

Admitted in the course of the year . 
Whole number .... 

Discharged 

Died _ 

Remaining, January 1, 1850, 

Of those discharged there were cured (from insanity), 

Thirty-six cases of delirium tremens, one of hysteria, and three of febrile 
delirium, also recovered. 

Causes of death. — Cholera 86, chronic diarrhoea 38, diarrhoea 10, dysentery 4, 
consumption 21, congestion of brain 12, apoplexy 5, epilepsy 5, paralysis 2, 
paralysie generale 3, typhoid fever 8, delirium tremens 3, erysipelas 2, old age 
4, and of scrofula, scurvy, suicide, albuminuria, typhoid pneumonia, chronic 
peritonitis, softening of the brain, dropsy, and exhaustion from exposure to 
cold, before admission, 1 each. 

There were more deaths in June and July than in the remaining ten months 
— a mortality caused by the prevalence of the cholera. The first case of this dis- 
ease was on the 10th of June, when there were 577 persons in the establishment, 
of whom 497 were patients. Of the whole number, 148 were attacked, and 91 
died. The greatest number of new attacks, on any day, was 15, on the 9th 
of July ; the last attack was on the 26th of the same month. " The principal 
sufferers were those who were usually lying about upon the floor or benches, 
regardless of their situation, and, in some cases, addicted to filthy habits, 
resulting from their demented state. Their physical condition was impaired 
generally." 

The subjoined table shows the duration of the disease, from the time of 
attack, in the 91 cases of death : — 

6 died in from 3 to 6 hours ; all were collapsed ab initio. 
18 " 6 to 12 hours ; all were collapsed ab initio. 

30 " 12 to 20 hours ; all were collapsed, apparently ab initio. 

16 20 to 30 hours ; all collapsed from 4 to 12 hours after attack. 

6 " 30 to 48 hours : 5 collapsed, 1 partially collapsed. 

4 died on the 3d day ; all partially collapsed, and died from prostration. 
4 died on the 4th and 5th ; 2 collapsed, 2 partially so ; all died from consecu- 
tive fever. 

7 died after the 5th ; 3 collapsed, 2 partially so ; all died from consecutive fever. 

" In those who were not entirely demented the intellectual powers were ap- 
parently improved during the severity of the disease ; but, at its subsidence, 
the mind resumed its previous condition." 

Of the 148 cases, there was neither diarrhoea nor vomiting in 1, no diarrhoea 
in 1, no vomiting in 5, and no cramps in 59. Diarrhoea, vomiting, and cramps 
occurred in 82, and complete collapse in 90. Premonitory symptoms were 
known to exist in 61, to be absent in 31 ; and there were 56, in regard to which 
this fact was unascertained. 

" In the case in which vomiting and diarrhoea were absent, there were severe 
cramps in the extremities, and extreme collapse, death occurring in three hours, 
followed by strong muscular contractions. The patient in whom diarrhoea was 
absent had severe cramps in the extremities and abdomen, excessive vomiting 
and feeble pulse, but recovered. The five in whom vomiting was absent were 
collapsed directly after the commencement of the disease. In one, cramps were 



1852.] 



American Insane Hospital Reports. 



179 



likewise absent. All died, in three, five, four, three, and sixteen hours respec- 
tively. Of the 59 cases in which cramps were absent, 13 were partially and 32 
completely collapsed: 36 of this number died." 

The term collapse is used here in reference to those cases alone in which the 
patient was pulseless. 

The erection of a new " Lodge" for violent patients, and of a large addition 
to the principal building, has given to the patients of this institution the addi- 
tional room which was so much needed ; and, rendering the improved manage- 
ment the more effective, has been of no little assistance in elevating the esta- 
blishment above the wretched condition which made it a " shame and a re- 
proach" to a Christian community. " Less restraint," says Dr. Ranney, " has 
been requisite, and frequently it has not been necessary, during the day, to apply 
any restraining apparatus, or even to confine a single patient to his room. The 
number of violent paroxysms, accidents, and attempts to commit suicide, has been 
lessened. At least one-third of the whole number of patients have been engaged 
in some species of labour." 

Why, Dr. Ranney, people who visited your institution in 1846 would hardly 
know where they were should they call there again. At that time, one would 
have as soon looked for a library at the sources of the Xile, or among the 
Esquimaux, as at that asylum ; but now the patients are supplied with " biog- 
raphy, history, geography, philosophy, theology, poetry, fiction," &c, and 
" free access to the reading-room has contributed much to the restoration of 
convalescents." That is as it should be. No more blessed resurrection has oc- 
curred within the limits of our experience. 

In the report of the visiting physicians, Drs. Ogden and Williams, it is 
remarked, in reference to the cases of cholera, that " several patients refused to 
take medicine, and those all died; while many in apparent extreme collapse 
recovered under medical treatment — an important fact, showing the fatality of 
the disease when left to the unassisted efforts of nature." 

By the report for 1850, it appears that the num- 
ber of patients, on the 1st of January, was 
Admitted in the course of the year . 

Whole number 

Discharged . . . . 

Died 

Remaining, December 31st, 
Of those discharged, there were cured 

Among the cures were 25 cases of delirium tremens. 

Causes of death. — Consumption 23, general debility 20, paralysis 6, paralysie 
generale 5, congestion of the brain 5, epilepsy 2, apoplexy 2, dropsy 3, stoma- 
titis 2, suicide 2, inflammation of the brain, diabetes, empyema, lumbar abscess, 
erysipelas, chronic diarrhoea, and old age, 1 each. 

The proportion of deaths, upon admissions, was four per cent, less than in 
1848, and ten per cent, less than in any other year ; that of recoveries was two 
per cent, greater than in 1848: and ten per cent, greater than in any previous 
year. Such are the expected, because the legitimate, results of the improved 
and still improving condition of the asylum. 

From motives of " economy" — whether domestic or political we cannot assert, 
though, judging from the management of some of the institutions upon Black- 
well's Island, while they were under the government of the common council 
of the city, we should strongly suspect it to be the latter — the convicts of the 
penitentiary have been employed as domestics and attendants at this esta- 
blishment. Some of the results of this system are thus alluded to in the 
report : — 

" The prisoners not only steal the clothing of the patients, but anything else 
of value that falls in their reach. As an illustration, the following case may 
be mentioned, as one from a great number of cases of a similar character. A few 
years ago, a young lady, who had been insane for some time, was admitted, 



Men. 


Women. 


Total. 


186 


215 


401 


195 


196 


391 


381 


411 


792 


138 


113 


251 


43 


34 




200 


264 


464 






179 



180 



Bibliographical Notices. 



[July, 



and, although partially demented, her self-esteem was gratified by the posses- 
sion of a beautiful head of hair. The morning after admission, it was observed 
that her head was completely shorn, and, after a long examination, the ringlets 
so highly valued were found in the possession of a prison aid in the hall, 
who had committed the theft for the purpose of selling them to a peruke- 
maker/-' 

The correction of this evil, by hiring suitable attendants, has been com- 
menced, and will, undoubtedly, be completed before long. Various improve- 
ments, both within doors and without, were made in the course of the year. 
Among the former is the allowance, "for the first time," to the patients, of 
knives and forks, in several of the halls. One of the best evidences of improve- 
ment, to persons who know the former condition of this asylum, is found in the 
gardener's report, where it is stated that an aggregate of 2779 days' labour was 
performed by the patients, between the 26th of May and the 31st of December. 
They raised twenty thousand cabbages, and other vegetables in proportion. 

The visiting physicians, in their report, say that the number of pauper luna- 
tics in New York city, on the 1st of September, 1834, was 116 ; whereas, on the 
1st of January, 1851, it was 464. " Estimating the future increase from these 
data, the city and county of New York will, fifteen years hence, have more 
than a thousand lunatics to be supported at the public charge." 

They suggest various improvements, which, if adopted and effected, will 
render this institution one of the best of its kind. At the close of the report, 
Dr. Williams resigns the place of attending physician. 

3. From the report for 1849, of Dr. Buttolph, of the New Jersey State Lunatic 
Asylum, we extract the following statistics : — 

Men. Women. Total. 



Patients in the Asylum, January 1, 1849, . 46 37 83 

Admitted in the course of the year ... 55 41 96 

Whole number 101 78 179 

Discharged 39 30 69 

Remaining, January 1, 1850, ... 62 48 110 

Of those discharged, there were cured 24 20 44 

Died 4 5 9 



Causes of death. — Exhaustion 5, consumption 2, chronic diarrhoea 2. 

" During the prevalence of the cholera, in neighbouring places, a marked 
epidemic tendency to affections of the digestive organs prevailed in the institu- 
tion ; but no death, or very alarming sickness of that character, occurred." 

The cure of a woman, insane more than eighteen years, and that of a man 
whose disease had existed upwards of six years, are reported. Of the former, 
Dr. B. says : " No expectation was entertained of her recovery by her friends 
or the officers of the institution ; and it must be regarded as a very unusual 
exception to the general rule of success, and to be attributed rather to a happy 
and rare effort of nature, than to the course of treatment adopted, which, at 
best, could only be considered as having favoured such a result." Of the latter 
he remarks, that in the recovery of the patient he was " also agreeably sur- 
prised, and could scarcely believe that a permanent cure had been effected, 
until some months of careful observation of his mental state had established 
the fact." 

Now, granting that both of these remarkable cures were, as is suggested of 
the first, the effect of a " happy effort of nature," the question may still be 
asked, If it be likely that the "happy effort" would have been crowned with 
such success, had the patients not been taken to an asylum ? We think it 
would not. Nature wanted just such assistance as can be and is rendered by 
a well-conducted institution. 

The principal part of this report is devoted to a detailed account of the 
management of the institution, its daily domestic duties, &c. &c. 

We proceed to the report for 1850. 



1852.] 



American Insane Hospital Reports. 



181 



Patients at the beginning of the year 
Admitted in the course of the year . 
Whole number . 

Discharged 

Remaining, January 1, 1851, 

Of those discharged, there were cured 

Died 



Men. 


"Women . 


Total 


act 

62 


A o 

48 


1 1 A 
110 


£ o 
oZ 


DO 


1 1 A 


114 


106 


220 


28 


30 


58 


86 


76 


162 


15 


17 


32 


6 


4 


10 



Causes of death. — Apoplexy 3, consumption 2, exhaustion 2, chronic mania 1. 

Dr. Buttolph makes the following remarks upon treatment : — 

"We use medicine sparingly, being influenced somewhat by the opposition 
that many insane have to taking it ; but more especially by the fact, that a 
physiological treatment is frequently quite as salutary as medical, and vastly 
more agreeable to the patient. Under the head of mental and moral treatment 
we include all those means and influences that can be brought to bear upon a 
person through the medium of the mind and feelings. Thus, the removal of 
a person from home, and the associations with which their excited, depressed, 
or perverted feelings have arisen, is often nearly all that is required to restore 
the healthy balance of the faculties. But, in addition to the effect of separa- 
tion from irritating causes at home, the new scenes, regulations, employments, 
amusements, and, indeed, the petty inconveniences and even annoyances met 
with in an institution, often have the effect, insensibly, to withdraw the attention 
of the patient from subjects upon which he has dwelt to his injury. Hence, 
treatment in an asylum is usually more successful than in private, and, as a 
general rule, is to be recommended. Occasionally, however, cases arise in 
which the question of removal from home can only be properly settled by an 
experienced medical adviser, or by resort to the experiment of change." 

After mentioning some improvements in the means of heating the buildings, 
which is done by steam, the report continues as follows: " As now working, 
we may safely challenge the world to produce another apparatus so perfect in 
the arrangement of its details, and so satisfactory in its results." 

Dr. B. recommends an enlargement of the building by the addition of two 
wings, one on either extremity of the present structure, and each to accommodate 
thirty-eight patients. 

4. Dr. Kirkbride, in the report of the Pennsylvania Hospital for the Insane, 
for 1849, says that the institution was full at the commencement of the year, 
and continued so until its close. The average number of male patients was 110, 
and of females 99. An additional wing, for the accommodation of twenty more 
women, was constructed in the course of the year. " When the institution was 
opened, in 1841, it offered accommodations for only 140 patients and their 
attendants. Since then, additions have been put up, at various times, which 
will now contain 80 patients with their attendants, making four new classes of 
each sex, and giving two fine infirmaries, and a great variety of fixtures and 
arrangements, of immense importance to the comfort of all, but which were 
scarce thought of in the commencement of the main building." 

The recent additions are heated by steam. " The character of the warm air 
from a steam or mild hot water apparatus," says Dr. K., " is so entirely differ- 
ent, and so incomparably more pleasant than that from the common hot-air 
furnace — its neatness, avoiding, as it does, all dust, dirt, or gas in the rooms, is 
so striking, and — after the first cost of the fixtures — its economy is so evident, 
that I feel no hesitation in saying that no one, who has had an opportunity of 
testing its advantages, will, with our present knowledge, be willing to see any 
other system than one of these adopted in any building like a hospital, whether 
for the ordinary sick or for the insane." 

Patients at the beginning of the year . . 200 

Admitted in the course of the year . . . 208 

Whole number . . 408 

Discharged 187 

Remaining at the end of the year . . . 221 
Of those discharged, there were cured . . 104 
Died . 19 



182 



Bibliographical Notices. 



Causes of death. — Pulmonary consumption 5, apoplexy 2, congestion of brain 
1, acute mania 4, chronic inflammation of the intestines 2, chronic organic 
disease of brain 1, exhaustion from high excitement 2, bronchitis 1, pericar- 
ditis 1. 

Upon the approach of the cholera, " every reasonable precaution was taken to 
avoid the exciting causes of that disease. When it is recollected that the 
epidemic prevailed for some time in our vicinity, and that a public institution 
within sight of us lost no less than two hundred and twenty-nine of its resi- 
dents, of whom seventy were insane, we must all feel that we have cause for 
devout thankfulness to a protecting Providence that I am able to record the fact, 
that not only was there not a single case of cholera in our household, but that 
there was no serious acute sickness of any kind, and less general indisposition 
than is commonly prevalent in the institution and its vicinity." 

" The museum and reading-room, put up by the patients and friends of the 
institution, and presented to it, as a Christmas offering, last year, has been in 
daily use, and has proved a source of great enjoyment to a large number of the 
inmates of the hospital." The report is ornamented with beautifully executed 
wood-cuts, representing the exterior and the interior of this building, so valu- 
able an acquisition to the inmates of the establishment. There are, also, similar 
views of the " Patients' Cottage" and the " Ladies' Summer House." 

Although the facilities furnished, at this institution, for the moral treatment 
of its patients, are not exceeded, perhaps not equalled, at any similar establish- 
ment in the country, yet Dr. Kirkbride, in his untiring philanthropy and his 
characteristic striving for the perfect, looks forward to more. "The treatment 
of the insane," says he, " has been gradually improved, till many persons 
believe that little more is to be accomplished. This, however, is a serious 
error, and ought to be disavowed by all who are familiar with the wants of the 
insane. Many highly important means of treatment are still to be procured, 
or their use widely extended, and nothing but an absolute want of pecuniary 
ability ought to prevent a much greater degree of efficiency than has ever yet 
been attained. Conspicuous among these means are the various measures con- 
nected with the direct mental treatment of the patients — important in all cases, 
even in those apparently the most hopeless — but indispensable for many whose 
diseases assume forms that make them peculiarly interesting." 

The report for 1850 is the tenth issued by the institution and by Dr. Kirk- 
bride. It contains so large an amount of valuable matter that, although there 
will be no difficulty in beginning to make extracts, yet we fear that it will not 
be so easy a matter to decide when and where to stop. 



Patients at the beginning of the year . . . 221 

Admitted in the course of the year . . . 207 

Whole number 428 

Daily average number 219 

Discharged 215 

Remaining at the end of the year . . . 213 

Of those discharged, there were cured . . 106 
Died ... . . . . . .27 



Causes of death. — Pulmonary consumption 5, acute mania 5, inflammation 
of brain 3, apoplexy 2, dysentery 2, general paralysis 2, softening of the brain 
2, exhaustion following excitement 1, chronic uterine disease 1, epilepsy 1, 
purpura 1, disease of heart 1, old age 1. 

Six of the patients died within two weeks from the time of admission. 

" While simple insanity does not often produce death, it unquestionably tends 
to lessen the average duration of life, by rendering the individuals labouring 
under it less able to resist attacks of acute disease, by the difficulty often ex- 
perienced in discovering sickness in its commencement, and by the resistance 
offered to the adoption of a proper course of treatment. There is, however, an 
acute form of insanity which does often cause death by a kind of exhaustion 
induced by the combined operation of long-continued mental excitement, want 
of sleep, and refusal of food. To distinguish these cases from ordinary insanity, 
to which they have little resemblance, the mode in which death has appeared to 



1852.] 



American Insane Hospital Reports. 



183 



be caused has been inserted in the table. When acute disease of the brain has 
been referred to, it is intended rather to designate active inflammation of that 
organ than insanity." 

After treating of the utility derived from the farm and garden, the workshop 
and mechanical department, and the museum and reading-room — the last of 
which has been found so useful that another, so that there shall be one for each 
sex, is desired — the report continues as follows: — 

"During nine months of the past year, the course of lectures and entertain- 
ments in the lecture-room was kept up regularly three times a week, to the great 
gratification and benefit of the patients and those employed in their care. I 
have no knowledge of such a course having been regularly continued for so 
long a period in any other institution, and it was interrupted only on account 
of the hot weather rendering the room uncomfortable for so large an audience. 
During this intermission, on several evenings of the week, the patients were 
entertained in other modes, on the lawn in front of the main building. 

" The practice of daily reading, by the teachers, to the patients in the differ- 
ent wards, especially those devoted to the more excitable class of patients, has 
been continued with marked good effect. 

" The entertainments in the lecture-room have almost entirely done away 
with the social parties for both sexes that, in the earlier days of the institution, 
were frequently given, and the effects of the former have been found, upon the 
whole, to be much more satisfactory. Frequent sewing parties are still held 
by the matron, among the ladies of the different wards, and a grand entertain- 
ment, for all in the house, is always expected on Christmas eve, preparatory to 
the special dinner given on the following day." 

A new feature has been added to the mental treatment, by the establishment 
of a library in each ward, of which there are sixteen. These libraries contain 
eleven hundred volumes. " A trial of three months has already been made 
with these books, and the result is most gratifying. The expressions of satis- 
faction, and of the benefit derived from them by the most intelligent patients, 
is of itself sufficient to show their great importance, and but three volumes, of 
little value, are reported to me as having been injured." 

We now come to that part of the report which has reference to the whole 
period of the existence of the institution. This is introduced by some, in our 
opinion, very just remarks upon statistics, from which we shall extract the most 
important passages. 

"The value of statistical tables, on any subject, must, in a great measure, 
depend upon the competency of the observer, and the care that is exercised in 
their preparation ; but the fact that there are some inherent difficulties in the case 
can scarcely be deemed a sufficient reason for making no attempt to overcome them, 
or not approaching as near as possible to absolute certainty. There seems to 
be no sound reason why the statistics of insanity may not possess as much 
certainty as those of most other maladies. Notwithstanding the false deduc- 
tions made by those who have carelessly analyzed these reports and tables, it 
must still be acknowledged that this evil will be likely to correct itself ; and it 
cannot be denied that, with all their defects, the general circulation of hospital 
reports, containing the results of judicious treatment, has done more to en- 
lighten the public mind in reference to insanity, to stimulate and give proper 
direction to the efforts of philanthropists, and eventually lead to a liberal pro- 
vision for the wants of the insane generally, than all other means combined. 

"One great error, often committed in reference to the statistics of hospitals 
for the insane, has been in using those from different institutions as a basis of 
comparison, without alluding to the varied character of these establishments, 
the kind of patients received, in regard to their curability and general health, 
the different modes prescribed for their admission, the authority to detain them 
for treatment without regard to the caprices of friends, and various other cir- 
cumstances having an important bearing upon the results, and without a full 
knowledge of and allowance for which, all comparisons are perfectly useless. 

" Of all the medical subjects that can be tabulated, the number is exceed- 
ingly small in which the statements are not, to some extent, matters of opinion, 



184 



Bibliographical Notices. 



and this latitude is as allowable in reference to insanity as to any other 
malady." 

Men. Women. Total. 

Whole number of patients admitted . . 999 807 1806 

" " discharged cured . . . 466 377 843 
of deaths . . . .104 72 176 

" The number of males in the institution has generally preponderated (over 
that of females) ; but not universally. In nearly every year, at some period, 
the number of the sexes has been equal ; and, at other times, there have been 
more females than males." 

The attention of those who have made themselves familiar with the reports 
of our institutions for the insane, during the last ten or fifteen years, must 
have been arrested by the fact that the number of females, not only absolute 
but relative to that of males, in those establishments, has been gradually in- 
creasing. While this truth indicates greater public confidence in the utility 
and the management of the hospitals, it throws a doubt upon what was believed 
to be a fact in former years — that the number of insane men in this country 
exceeds that of insane women. 

" Among the cases embraced in this report, by far the most prevalent cause 
of insanity has been ill health of various kinds, and in about the same propor- 
tion in both sexes. Intemperance is set down as the direct cause, in 106 (out 
of 1806) patients, of whom 97 were men and 9 women. This, however, is far 
from showing its real influence in the production of the disease. It tells no- 
thing of its effect on others, nothing of the blighted hopes, the losses of pro- 
perty and character, the domestic difficulties and the mental anxiety, deep and 
depressing, which follow in its train and owe their origin to its existence. Loss 
of property, directly or indirectly, is a not unfrequent cause of insanity, affecting 
men much more than women ; while domestic difficulties are a vastly more 
common cause of its existence among females than males." 

Fifteen cases, ten men and five women, were attributed to fright. They 
" were well marked, and resulted directly from that cause." After mentioning 
various other causes, the report continues: "Two cases in men and five in 
women, are reported as caused by the use of opium ; and four in men, by the 
use of tobacco. Opium is much more used by females than males, and its 
effects upon the mind, no less than upon the body, are of a most injurious cha- 
racter. The use of tobacco has, in many individuals, a most striking effect on 
the nervous system, and its general use in the community is productive of more 
serious effects than is commonly supposed. I have never seen anything more 
than a temporary annoyance result from its entire discontinuance, and by that 
course alone the complete re-establishment of impaired health has often been pro- 
duced.^ 

Some physicians report the loss of sleep as a not infrequent cause of mental 
derangement. Dr. K. gives no case from this origin, as he has found that the 
loss of sleep arose from some antecedent cause, or was the effect of the insanity. 

When the physicians to asylums have deprecated the practice of general 
bleeding in insanity, they have frequently been met by the argument that they 
do not receive patients until the acute stage has passed away, and that, con- 
sequently, their authority for the treatment of that early stage cannot be valid. 
Of the 1806 cases reported by Dr. Kirkbride, in no less than 913 the disease 
was of less than three months' duration. It is not unreasonable to suppose 
that a large number of these had not existed two months, and many of them 
not one. Now, where are there any ten physicians, in general practice, in 
one city or vicinity, whose combined experience in the treatment of even acute 
insanity is equal to that of Dr. Kirkbride's ? And yet we venture the asser- 
tion — and we call upon the Dr. to correct us, if we are in error — that, in all 
these 913 cases, Dr. K. has not practised venesection, for insanity, in a single 
instance. He may have done it for apoplexy, or congestion of the brain ; but 
for mania, melancholia, or any of the maladies generally included under the 
name insanity, we presume to say never. 



1852.] 



American Insane Hospital Reports. 



185 



But perhaps we shall be referred to the authority of Dr. Rush, whose work 
on mental disorders is the only one generally known in this country. If so, 
we have two answers and another authority to offer. First : If, in the time of 
Dr. Rush, venesection actually was the best treatment for insanity, it does not 
necessarily follow that it is so now. Second : We consider the authority of Dr. 
Kirkbride, in the treatment of this disease, as of far greater weight than that 
of Dr. Rush, and that simply because we believe his experience to have been 
greater. Now for our authority ; and it comes from a high source, the centre 
of London. In the early part of the present century, the system of treat- 
ment at Bethlem Hospital for the insane " consisted of bleeding, purging, and 
vomiting, in the spring months. A certain day was appointed on which thepatients 
were bled; another when they were purged; another when they were vomited. They 
were bled in May, and again in June, the precise time depending on the 
weather." The two authorities are contemporaneous. The latter is from an 
hospital so elevated in its position, that it is the only one, in the whole king- 
dom of Great Britain and Ireland, which is exempted from the inspection and 
surveillance of the Commissioners of Lunacy, and whose physicans, it must, 
therefore, be presumed, are among the most eminent in London. 

But the physicians of probably nineteen-twentieths of the institutions for the 
insane, not only in America and Great Britain, but in France, Prussia, and 
Austria, condemn the practice of general bleeding, in insanity, unless it be in 
rare and exceptional cases. 

Dr. Kirkbride has found mania to be the most curable of any of the specific 
forms of insanity. Next, in this respect, follows melancholia. Monomania 
occupies the third place ; and the least proportion of cures — fifteen in two hun- 
dred and twenty-one — was in dementia. 

We close our notice of this report with an extract relating to the provision 
for the insane in Pennsylvania. 

" It is now just about a century since the Pennsylvania Hospital, the pioneer in- 
stitution for the insane in America, was incorporated by the Provincial Assem- 
bly, and opened for the reception of patients. With the exception of the Friends' 
Asylum, at Frankford, established in 1817, and an Insane Department of the 
Philadelphia Almshouse, at Blockley (which, a few years since, for the first 
time, took rank as a curative establishment), the Pennsylvania Hospital has 
been the only institution in the State to which any class of her citizens could 
resort for the treatment of insanity, and it was, strictly, the only one which 
offered relief from this malady, without cost, to the indigent of Pennsylvania. 

" From the foundation of the Pennsylvania Hospital, in 1751, to the present 
time, 6062 insane persons have been admitted and treated in its wards. Of 
these, more than 1000 were poor, who received every care and attention without 
charge of any kind, and of whom a large proportion were restored to their 
families in perfect health, and many others, in various states of improvement ; 
the number of this class, under treatment, being limited only by the income 
of the institution. 

" It will be a fitting commemoration of the services rendered by a private 
charity to all classes of the insane, but especially to the indigent insane of 
Pennsylvania, during a whole century, that, exactly at the end of that period, 
our noble Commonwealth will have prepared and put in operation a State Insti- 
tution,* intended to afford relief to all her citizens who labour under loss of 
reason, and which, with a judicious organization, and fostered by liberal and 
enlightened legislation on the part of the government, cannot fail to spread 
blessings of inestimable value throughout the community. 

" When the new institution is in operation, about one thousand insane patients 
will be comfortably provided for in the State, and, except an hospital in its west- 
ern part, Pennsylvania will require no material extension of the accommoda- 
tions for her insane, for many years, although important improvements will be 
desirable in all the existing institutions." 

5. The official year, of the "Asylum for the Relief of Persons deprived of 
the use of their Reason," at Frankford, Pa., commences with the 1st of March. 



At Harrisburg. It is now in operation. 



186 Bibliographical Notices. [July? 

Men. Women. Total. 

Number of patients, March 1, 1848 . . 24 31 55 

Admitted in the course of the year 19 19 38 

Whole number 43 50 93 

Discharged 46 

Remaining, March 1, 1849 .... 47 
Of those discharged, there were cured . . 25 
Died . . . ..... 5 



Causes of death. — Effects of long excitement 1, organic disease of the brain 1, 
old age 1, tumour on the brain 1, acute mania 1. 

Schools and lectures constitute a part of the moral or mental treatment of 
the patients. " The experience of the past year," says the report, " confirms 
the opinion heretofore expressed, of the great utility of mental occupation, as 
well as bodily labour, in the curative treatment of the insane ; and also its 
great importance in promoting the comfort and well-being of those who are 
incurable. It is not to be expected that the latter class should be capable of 
making much advance in learning, though their mental powers are certainly 
strengthened, and more developed by being brought into use, and stimulated 
by exercise; but, independent of this, important benefits result to them, from 
the efforts made to interest and employ their minds, inasmuch as they soon 
begin properly to appreciate the care and attention required to instruct them, 
and manifest their willingness to repay it by increased correctness of deport- 
ment." 

In the course of the year, means of forced ventilation were introduced into 
some parts of the building, the old bath-rooms were improved, and two new 
ones arranged. 

The leading statistics, from the report for 1849, are as follows : — 

Men. Women. Total. 



Patients at the beginning of the year 24 23 47 

Admitted in the course of the year 16 11 27 

Whole number 40 34 74 

Discharged 26 

Remaining at the end of the year ... 48 

Of those discharged, there were cured . . 14 

Died 4 



Causes of death. — " Obstruction of the bowels" 1, acute bronchitis 1, typhoid 
fever 1, suicide 1. 

" Although the cholera prevailed at Frankford and in the vicinity of the asy- 
lum, yet the inmates of the institution were mercifully preserved from its fearful 
visitation; but, during the last summer and the first fall months, epidemic 
dysentery prevailed, to a considerable extent, among the patients and their 
attendants." 

The report says that " a detailed description of the means that have been 
employed (in treatment), would be little more than a repetition of the matter 
of previous reports," and, consequently, no such detail is given. We find a 
similar idea expressed in the reports of several other institutions. Now, so 
far as our observation has extended, comparatively few people read the reports 
of asylums for the insane, other than physicians and those who have some 
near relative or friend suffering under mental alienation. Hence, a very large 
proportion of those readers is constantly changing. The new class of them are 
mostly ignorant of the modern method of treatment, and ought, as they gene- 
rally wish, to be enlightened thereupon. It has, therefore, long been our opinion 
that each report of every institution should contain a description of the moral 
treatment, so full as to give a clear comprehension of it to a person previously 
without any knowledge upon the subject. 

At or about the commencement of the official year for 1850-51, an important 
change was made in the organization of the Frankford Asylum, by making a 
physician its superintendent or principal officer. Dr. Joshua H. Worthington, 



1852.] 



American Insane Hospital Reports. 



187 



-who, for several years, had been the resident physician, was appointed to the 
place. He is well qualified for the fulfilment of its duties. 



Patients at the beginning of the year 
Admitted in the course of the year 
Whole number .... 
Discharged .... 
Remaining, March 1, 1851 
Of those discharged, there were cured 
Died 



48 
20 
68 
25 
43 
12 

9 



" In general," says Dr. Worthington, " the time required for the cure of any 
case of insanity will depend on the promptness or delay with which the 
patient is submitted to proper treatment. The earlier the treatment is com- 
menced, the more speedy will be the recovery ; and the reverse. We occa- 
sionally, however, meet with cases of long duration, in which the condition 
of the patient has been much neglected, or where the disease may have 
been kept up by improper treatment, which recover rapidly when placed 
under different circumstances. An instance of this kind was that of a young 
man from one of the interior counties of this State, who was discharged during 
the last year. He had been insane for two years previous to his admission, 
and, at the commencement of the attack, had attempted to take his own life 
by leaping into a well, and afterwards had been kept bound with chains. 
Under our care, he recovered in the course of a few months ; and, during the 
period of nearly a year that has elapsed since his return home, he has continued 
entirely well, and been usefully employed in the management of a farm/ 7 

In regard to the curability of insanity, Dr. W. states, that, " in this institu- 
tion, with the reception of all classes, and the disadvantage of premature 
removals, the percentage of cures of recent cases, since 1842, is 72.25, there 
having been received, since that time, 191 cases of that description, of which 
138 have been restored. If to this we add 10 per cent, as the probable loss 
sustained by premature removals, we shall have 82.25 per cent., which may be 
considered as nearly representing the proportion in which recent cases of in- 
sanity are curable. During the same period, 121 chronic cases have been admit- 
ted, 24 only of which, or 19.83 per cent., have been restored; the proportion of 
cures, on the whole number received in that period, being 51.92." 

6. Dr. John Fonerden became connected with the Maryland Hospital in 1846 ; 
but no report, written by him, was published until the close of 1849. This re- 
port, therefore, contains the statistics of four years. 

Patients at the hospital, January 1, 1846 
Admitted in the course of four years 

Whole number 

Discharged 

Remaining, December 31, 1849 
Of those discharged, there were cured 
Died 

" There were admitted, exclusive of the patients enumerated above, 107 
private boarders affected with mania a potu. All of these were discharged 
recovered, except three who died. As asylums for the insane are not appro- 
priate places for cases of this character, it will probably be discovered, in the 
progress of moral intelligence, that it is a proper function of the Temperance 
Societies to adopt the plan of building, on a farm near each of the principal 
cities, a suitable retreat ; to be conducted, under the advice of a physician, by 
managers of mature age and discretion, who, having the promotion of tempe- 
rance in view, and sufficient leisure, would aim, by their personal aid, to lead 
young men, after recovering from the dreadful malady, to love sobriety and 
usefulness of conduct." 

" The number of recent cases of insanity admitted during the four years," 



Men. 


"Women. 


Total. 


58 


49 


107 


139 


113 


252 


197 


162 


359 


131 


95 


226 


64 


69 


133 


43 


36 


79 


40 


17 


57 



188 Bibliogra^Tiical Notices. [July? 

continues the report, " was very small. Almost all the cases were of more 
than one year's duration before admission." 

Dr. F. mentions the defects of the hospital, and the necessity of a " thorough 
reform." He evidently looks forward to a new architectural arrangement of 
the building, or to the erection of a new one, in a more suitable place. "We 
hope that no considerations will induce the managers of that institution to de- 
cide upon the former course. Between the investment of a pretty large amount 
of funds in the attempt to make the present establishment what a hospital for 
the insane ought to be, and throwing the same sum into the river, there would 
be, in our opinion, but little choice. 

In allusion to defective training, in early life, as a cause of mental disorder, 
the report closes with the following beautiful effusion of the heart of a father 
and, in the best and noblest sense of the'term, a man : — 

" How important is it, then, that childhood and youth should be gently led, 
by a patient and loving help, both in play and at pleasant work, into innocent 
habits of the mind, and, in agreement therewith, into bracing habits of the 
body. For, so far as such conjoined habits become identified with the physio- 
logical life, they will combat, triumphantly, many a hereditary peculiarity, 
mental and corporeal; and they will be strong in vital power to resist the 
invasion of disease. More than this; becoming, in due time, subservient 
to the religious principle, in its legitimate works of sincerity and justice, they 
will surely generate a purity of purpose in the discharge of domestic and all 
other duties ; and thus, by exempting the mind from an abiding presence of 
selfish thought and inclination, they will be a safeguard against most of the 
secondary causes of disordered ideas and emotions, of incoherent speech and 
impulsive actions. So may the human mind, apart from the blighting power 
of unavoidable disease and accident, gradually work out its emancipation from 
the infirmities of a natural temperament ; so can it earn the faculty of living 
in freedom according to reason." 

Statistics from the report for 1850 : — 



Patients at the beginning of the year 
Admitted in the course of the year 
Whole number . 
Discharged .... 
Remaining at the end of the year 
Of those discharged, there were cured 
Died 



Men. Women. Total. 

64 69 133 

25 15 40 

89 84 173 

21 11 32 

68 73 141 

8 6 14 

5 16 



Seven cases of mania a potu were also received, and discharged cured. 

Dr. Fonerden calls the attention of the President and Board of Visitors to 
the necessity of providing additional accommodations for the insane, in the 
State of Maryland. The only argument adduced is the impossibility of re- 
ceiving all the applicants at this institution. "It may now happen," says he, 
"that one or two months will elapse before another public patient can be 
received. In the mean time, urgent applications will continue to be made for 
the relief of the public and of families, and for the protection of the destitute 
insane, whose cases, in most of the counties, are dependent upon this institution 
for custodial arrangements. On the day of writing this, applications have been 
made for the admission of three patients at the expense of the counties." 

P. E. 



1852.] 



Meigs' Obstetrics. 



189 



Art. XVIII.— Obstetrics : The Science and the Art, By Charles D. Meigs, M. D., 
Professor of Midwifery, and the Diseases of Women and Children, in Jeffer- 
son Medical College, at Philadelphia, etc. etc. Second edition, revised. With 
one hundred and thirty-one illustrations. Philadelphia, Blanchard & Lea, 
1S52: 8vo. pp. 759. 

The work of Dr. Meigs, whether as a treatise adapted to indoctrinate the 
student into the science and the art of obstetrics, or as a table-book, for frequent 
reference on the part of the practitioner, has been already assigned, by the 
almost unanimous verdict of the profession, a very high rank among the nume- 
rous kindred works received as authoritative in this country and in Europe. 

In the general correctness of its theoretical teachings, and the fulness, expli- 
citness, and excellence of its practical directions, throughout the whole scope 
of the science and the art of which it treats, the volume before us will certainly 
bear a favourable comparison with the most esteemed of the obstetrical treatises 
in common use, while, in some respects, it appears to us better adapted than 
many of them for the instruction of the student and young practitioner. 

The opportunity afforded by the demand for a second edition has been made 
use of by the author for introducing many improvements in the matter and style 
of the treatise, considerably augmenting the text, recasting some parts and can- 
celling others; while the literary execution of the whole has been subjected to a 
careful revision. 

It is not our intention to enter upon an examination of the several additions 
and revisions that have been made in the present edition of Dr. Meigs's work, 
nor do we esteem this necessary, as it will, of course, very speedily find its way 
into the hands of the majority of American practitioners, to whom we can, with 
much confidence, recommend, it, as embodying a very full exposition of the 
doctrines and practice of obstetrics — a sure guide to the learner, and, at the 
same time, a safe counsellor to the young practitioner in cases of doubt and of 
difficulty. 

We confine our remarks, however, to that portion of the work which treats 
strictly of obstetrics — the science and the art. In the sections appropriated to 
the consideration of the pathology and therapeutics of the female, there are 
many important points, in relation to which we entertain opinions very differ- 
ent from those advanced by the author ; opinions which we believe to be based 
upon accurate and accumulated observations — our own, as well as those of other 
practitioners in this country and in Europe. 

The views advanced by Dr. Meigs in relation to puerperal fever — its nature 
and its treatment — though enforced with a plausibility and earnestness which 
would almost persuade us to receive them as true, are certainly calculated 
to lead the young practitioner into error. While it is admitted that peri- 
toneal inflammation, or metritis, occurring in the puerperal female, though 
a disease, when neglected in its earlier stage, most dangerous and rapidly 
fatal, has nothing specific in its character, and may be disarmed of its vio- 
lence, in a large number of cases, if attacked at its onset by bloodletting and 
other active antiphlogistic remedies, still numerous incontestable facts prove, 
beyond the possibility of doubt, that the parturient female is also liable 
to be attacked by a fever, which is peculiar in its character, communicable from 
the sick to the well, and by the intermediation of those who have been in im- 
mediate contact with the sick, and which holds a very close relationship to 
certain forms of erysipelas. This fever is in all cases attended by peritonitis, 
metritis, or uterine phlebitis ; but there exists also, from the onset, a peculiar, 
morbid element, a diseased condition, probably, of the blood, which gives to it 
a specific character, and peculiar malignancy. This form of puerperal fever 
most commonly occurs as an endemic. While it is scarcely controllable by any 
course of medication, experience has shown that in its treatment direct deple- 
tion by the lancet, as well as the other antiphlogistic remedies, are inad- 
missible. 

As a historv of the ordinary forms of puerperal peritonitis and metritis, we 
No. XL VII. — July, 1852. 13 



190 



Bibliographical Notices. 



must admit the entire correctness of the account given by Dr. Meigs of what he 
terms child-bed fever, and recommend it to the closest attention on the part of 
the student and practitioner. Nor do we feel inclined to dispute the general 
outlines of the author's views in respect to its pathology, or to call in question 
his directions for its treatment. The objection we make is that, in treating of 
the subject of child-bed fever, Dr. Meigs has not covered the whole ground — 
that he has omitted an important form of puerperal fever, marked from its very 
onset by the most unequivocal indication of adynamia, and in regard to which 
neither his pathological nor therapeutical views are true ; and that, by this omis- 
sion, they who consult his work for instruction will be misled, by supposing that 
all cases of child-bed fever consist simply in inflammation of the womb or of 
its veins, or in inflammation of the peritoneum, and that free and early blood- 
letting is the only remedy upon which any reliance in their treatment can be 
placed; and though experience and careful observation will not fail to convince 
them of the inaccuracy of both propositions, it must, nevertheless, be at the 
expense of no little mortification, and professional disappointment. 

In his pathology of cyanosis neonatorum, Dr. Meigs, we believe, stands 
alone ; and certainly in opposition to all the recorded facts derived from morbid 
anatomy. In evidence of the correctness of the views advanced by him, he 
adduces a series of cases to. show that cyanosis may be cured by placing the 
infant in such a position as he supposes will cause the weight of the blood to 
force down the valve of Botallus upon the open foramen ovale, and thus pre- 
vent the d.irect passage of the blood from the right into the left cavities of the 
heart. That in many cases of partial asphyxia occurring in children from 
causes unconnected with organic lesions of the respiratory or circulatory sys- 
tems, almost immediate relief will be derived by causing the patient to assume 
the position indicated, is certainly true ; it is even true, that in unquestionable 
cases of true cyanosis, all the prominent symptoms will frequently be very con- 
siderably relieved for a time by the same means ; this does not prove, however, 
that the relief in these instances is caused by the closure of the open foramen 
in the septum between the two auricles of the heart. Such an explanation is 
a mere hypothesis, unsupported by any direct evidence ; and in pathology, one 
hypothesis cannot be received in proof of the correctness of another. 

D. F. C. 



Art. XIX. — The History, Diagnosis, and Treatment of the Fevers of the United 
States. By Elisha Bartlett, M. D., Professor of Materia Medica and 
Medical Jurisprudence in the College of Physicians and Surgeons of the 
University of the State of New York, etc. etc. Third edition, revised. 
Philadelphia, Blanchard & Lea, 1852: 8vo. pp. 595. 

As a faithful exponent of the present state of public opinion in relation to the 
history, pathology, etiology, diagnosis, and treatment of the fevers of this coun- 
try, the work of Dr. Bartlett becomes a valuable if it be not an essential addition 
to the library of every physician, and we are pleased that the profession have 
so far endorsed this opinion as to require the issue of a third edition, thus giving 
the author an opportunity, of which he has industriously availed himself, to 
incorporate in the different chapters of the treatise whatever additions recent 
investigations have added to our knowledge of the several subjects discussed. 

In treating of the fevers of the United States, Dr. Bartlett has not contented 
himself with a mere synopsis of the facts and opinions of the leading writers on 
the subject, but has carefully analyzed and compared their various observations 
and deductions, and has selected such only as appear to him to present most 
clearly the indications of accuracy and truth. 

Dr. Bartlett strongly asserts the specific character of each of the four forms 
of fever described by him, namely, the typhoid, the typhus, the periodical, and 
the yellow fever ; each of which, in his opinion, differs essentially from all the 
others. That ordinarily the several forms of fever alluded to present each well- 



1852.] Hooker and Routh on Homoeopathy. 191 



marked distinctive characters is unquestionably true, and yet all are aware that 
cases do occur in which the diagnosis is by no means so easy. Protracted 
remittents assume, not unfrequently, very much the characteristics of typhoid 
fever, if they do not in fact occasionally run into the latter. We have repeatedly 
seen the phenomena of typhoid and typhus fever so intimately blended in the 
same patient as to render it impossible to determine under which of these 
forms of febrile disease he was actually labouring, while the more intense grades 
of bilious remittent fever are often with difficulty distinguished from yellow 
fever. 

However, Dr. Bartlett has certainly the weight of medical authority in favour 
of the views advanced by him upon this subject. We ourselves only doubt the 
specific difference of the several forms of essential fever, having seen no incon- 
testable evidence by which this difference is established ; but we, at the same 
time, candidly admit, that we have no positive facts to prove that these several 
forms are mere modifications of one and the same disease. D. F. C. 



Art. XX. — Homoeopathy: An Examination of its Doctrines and Evidences. 
[Fiske Fund Prize Dissertation.] By Worthington Hooker, M. D. New 
York, 1851: 12mo. pp. 146. 

On the Fallacies of Homoeopathy, and the Imperfect Statistical Inquiries on ivhich 
the Results of that Practice are estimated. By C. H. F. Routh, M. D., M. R. 
C. S. London, 1852: 8vo. pp. 85. 

Dr. Hooker's essay is essentially the same with the chapter on homoeopathy 
in his work entitled "Physician and Patient," and which has been reviewed 
in this Journal. It is intended, we presume, even more than that work for 
popular instruction. It contains much logic and much sarcasm directed 
against the infinitesimal nonsense and the psoric absurdities of Hahnemann's 
followers, much more than was necessary for annihilating all that is really vital 
in these vexatiously minute parasites on the body medical. We cannot con- 
gratulate the accomplished author on his success in hunting such small game ; 
the trophies of the chase are hardly worth the bringing home. 

The real doctrine contained in the homoeopathic system is quite as inde- 
pendent of these fooleries as the latter are of one another. The practice rests 
upon a tripod, of which the three legs have no physical or metaphysical con- 
nection whatever, and which are ludicrously unequal in size, so that the fabric, 
taken as a whole, tumbles to pieces upon the slightest touch. Not so the 
homoeopathic doctrine. It was conceived and matured before the quackish 
instincts of Hahnemann felt that it might be made profitable by linking it with 
a trade, an idea which may very naturally have taken possession of him during 
his residence among the money-changers of Leipsic, where his brazen image 
now appropriately adorns the market-place. " Psora" and " globules" were 
spells invented to lure the silly mob who could not be stirred by any merely 
scientific charm. Had the formula of similia similibus been propounded by an 
honest physician, i tmight have excited discord, and, like the Brunonian 
and other hypotheses, even have arrayed the medical profession in opposing 
camps. Like these, too, it would more speedily and certainly have achieved 
whatever good it was capable of. But while by itself it was merely a contro- 
vertible proposition, it became the scoff and jest of the medical world, by being 
linked with propositions intrinsically preposterous and absurd. 

Hahnemann tells us that homoeopathy was the result of his own reflection 
and observation. It may have been so ; but he was certainly not the first who 
entertained the like notion of medicine. Dr. Hooker quotes from Stahl a pas- 
sage which explicitly contains the homoeopathic doctrine : " The received 
method in medicine of treating diseases by opposite remedies, that is to say, 
by medicines which are opposed to the effects they produce, is completely false 



192 



Bibliographical Notices. 



[July, 



and absurd. I am persuaded, on the contrary, that diseases are subdued by 
agents which produce a similar affection — burns by the heat of a fire to which 
the parts are exposed ; the frost bite by snow or icy cold water ; and inflamma- 
tions and contusions by spirituous applications." Nor was Stahl a whit less 
arrogant in his pretensions than the completer of his doctrine: " What I write," 
he exclaims, "the grace of God has taught me and the "sage of Ccethen" 
allows of no compromise between his dogma and other doctrines, as if Nature 
possessed but one possible means of achieving her purposes. 

In his zeal to expose the folly of the homoeopathic system, Dr. Hooker goes, 
we think, beyond the limits of sound reasoning ; in his legitimate aversion to 
accepting as an exclusive dogma the similia similibus curantur of Hahnemann, 
he seems inclined to subscribe to the equally exclusive contraria contrariis 
medentur of Galen. He, therefore, attempts to explain away the illustrations 
which the homoeopathists, and before them Stahl, have cited in support 
of the former doctrine. According to him, the application of cold to restore 
the vitality of a frosted limb is not an illustration of the homoeopathic princi- 
ple. A limb that is frozen has lost its heat, and is to be restored by the com- 
munication of heat to it, says Dr. Hooker ; and if this be done by snow or ice, 
the author contends that the cure is effected by heat and not by cold. Such 
a distinction strikes us as not very logical. Unquestionably, cold relieves 
the ailment which cold has produced. So, too, of another illustration. Heat 
relieves superficial burns. But Dr. Hooker thinks that this " is not an example 
of like curing like, but of same curing same, which is quite another thing." 
The distinction, we confess, eludes our comprehension. But if this illustration 
be unsatisfactory, surely the plan of treating burns by stimulants, according to 
Kentish's method, is open to no objection as an illustration of homoeopathic 
cure. But our author thinks that, unless turpentine were actually capable of 
producing the condition of the skin it is alleged to cure, the method is not 
homoeopathic. This, we conceive, is scarcely fair. A superficial burn may be 
cured by holding it to the fire, by turpentine, by ice, or by cold water, by lime- 
water and sweet oil, by raw cotton, &c. It will not be pretended that the mode 
of action of the first two applications, and those of the following ones, are 
identical. Will not every one allow them to be opposite ? The former is the 
homoeopathic, the latter the allopathic method ; and either is appropriate, even 
in the identical conditions supposed. 

The illustrations here presented are amongst the most striking which the 
subject affords, and, as has been seen, were adduced even by Stahl; but there 
are many others made familiar by every day's experience. Emetics are con- 
stantly given to relieve nausea and slight vomiting, by inducing a complete 
evacuation of the stomach ; purgatives cure the diarrhoea excited by irritatiag 
ingesta, and not that only, but to arrest the discharges of dysentery ; alcohol 
cures delirium tremens ; nitrate of silver suspends urethral and other inflam- 
matory discharges ; blisters arrest erysipelas, &c. In all of these, and many 
analogous instances, the remedy has the faculty of producing in the healthy 
state a condition analogous to that it is capable of curing in a state of disease. 
Such examples avail no more to demonstrate the truth of the homoeopathic 
theory, than the more numerous and familiar facts of daily experience warrant 
the adoption of an exclusively allopathic theory. Natural truth is no more to 
be pressed into the artificial formulae of scientific systems, than the varied, 
graceful, and ever-changing types of living beings can be represented by mathe- 
matical diagrams. Science is not in systems, but systems are artificial enclo- 
sures in the field of science. Truth lies without as well as within them. The 
pretension of Hahnemann to limit the power of medicine in curing disease to 
a certain, and that rather an exceptional mode of action, was neither more nor 
less than has been done by medical philosophers from Galen to Liebig. Had 
he done no more than this, he might have effected real good by enlarging the 
limits of our knowledge. But when he put forward as essential parts of his 
system the inane, absurd, and wicked doctrines of infinitesimals and psora, 
the man of science disappeared behind the mask of the charlatan, and the 
medical profession instinctively shrank from all communion with a convicted 
impostor. In this case, as in that of a still more famous quack, there is no 



1852.] 



Hooker and Routh on Homoeopathy. 



193 



reason why we should not accept what may be true in the teachings of Hahne- 
mann, as we hare adopted what was true in the ravings of Paracelsus. Perhaps, 
too, the best antidote to the gross extravagances of the latter is to be found even 
in the subtle and shadowy unrealities of the former. The question, the capital, 
the vital question is, wliat will cure disease ? Once settled, we may inquire how 
is disease cured ? Till the former question is decided, the latter is a conflict 
about systems, a mere war of words, never ending, still beginning, and appa- 
rently as far from a solution now as it was two thousand years ago. If the 
facts of therapeutics really admit of being arranged in two classes, according 
to the likeness or unlikeness of the natural effects of remedies to the diseases 
they cure, science can but gain by this truth being known. Its value would 
be none the less because a portion of it formed part of the system of a notorious 
charlatan of the nineteenth century. Posterity would smile at its rejection, 
upon that ground, by a generation that piques itself upon being philosophical. 
But, admitting the occasional application of similia similibus to the phenomena 
of therapeutics, we must be careful lest the doctrine seduce us into a too general 
application of it, lest we elevate the exception to the dignity of a rule. Even 
as a matter of medical faith, it were well for this point to be clearly appre- 
hended. Otherwise the weak-minded might be seduced into believing a revolt- 
ing heresy, and the weak in conscience might find in our restricted and 
philosophical assent to a theory, an excuse for all the deceit and crime which 
are in practice associated with subscription to the theory by its exclusive par- 
tisans. 

Dr. Routh's essay attacks homoeopathy from a scientific position. After 
exposing, as so many others have done, the arithmetical absurdities of the infi- 
nitesimal calculations, and the bad grace with which it is defended by some of 
its less ignorant and more honest promoters, and further, the knavish practice 
of concealing under the form of innocent-looking globules, large, dangerous, and 
even fatal doses of the vegetable alkaloids, the author devotes himself to an exami- 
nation' of the statistical returns which are relied upon, when reason fails, to con- 
firm the faith of homoeopathic patients, and, perchance, practitioners too. He 
has taken a great deal of unnecessary trouble to show that, all other circum- 
stances being equal, the mortality of a given disease varies greatly in different 
countries, and that, consequently, such rate of mortality is not by itself an 
index of the value of the treatment employed. This element would certainly 
be one of weight and value in comparing accurate and trustworthy statistics 
proceeding from several countries ; but it ceases to have any value so soon as a 
portion of the statistics are proved to be false. The jurisdiction of the case is 
changed ; it must be transferred from the court of science to the criminal ses- 
sions, where the defendant, if guilty, not only will lose his cause, but be 
branded with infamy. 

Passing over, then, the very interesting illustrations of the power of the 
imagination to cure disease, when appealed to boldly and confidently, we come 
to the more important part, in which the fallacy of homoeopathic statistics is 
exposed. The statements of mortality in the homoeopathic hospitals are shown 
to be between seven and ten per cent., on an average, lower than in medical 
institutions of the same kind ; and are also shown to rest in part on the very 
convenient method of excluding all moribund cases from the tables of the 
former. The cases, too, in homoeopathic and medical hospitals are not identical. 
The author relates, of his own knowledge, that in Fleischmann's Hospital, at 
Vienna, the serious cases are few and far between; the milder cases, on the 
contrary, of frequent occurrence ; and he gives a numerical statement of a large 
proportion of the diseases which figure in the list of admissions, many of which 
require no active treatment at all, and not one that is ever fatal by itself. The 
proportion of cases of phthisis received into hospitals generally may be inferred 
from Dr. Routh's instances to vary between 4 and 9 per cent., while in two 
principal homoeopathic institutions they do not exceed 1.6 per cent. ^ Besides, 
in Fleischmann's institution he has the sole control over the admissions, and 
there is no check at all upon his diagnosis. It is remarkable, too, as showing 
how mild in general are the cases received into homoeopathic hospitals, that 



194 



Bibliographical Notices. 



[July, 



they receive a very much larger number of patients in proportion to the num- 
ber of beds, than medical hospitals do. The author follows the statistics of 
homoeopaths in different diseases, and proves conclusively that there is pro- 
bable ground for believing the cases of diseases to be selected and their diag- 
nosis wrong. His mode of treating the subject does not allow of much conden- 
sation; and we, therefore, conclude this notice of his laborious and minute 
comparisons, by transcribing a part of the general conclusions at which he 
arrives : — 

In the homoeopathic cures effected, globulism is absolutely for nothing ; and 
the practitioner who would attribute such cures to globulism must be con- 
sidered as either full of simplicity, or a friend to quackery; but they are due — 

1. To the influence of the mind on the body, through the voluntary or emo- 
tional systems. 

2. To the vis medicatrix naturae. 

3. To excellent dietetic regimen. 

4. To allopathic [medical] treatment surreptitiously conjoined. And, se- 
condly — 

1. That in many cases the homoeopaths are inexact and inaccurate in their 
diagnosis. 

2. That, therefore, their statistical returns are in many cases falsified. 

3. That they allow nothing for the different and varied circumstances under 
which different patients are placed, as type, comfort, locality, idiosyncrasy, &c. 

4. That their comparisons with allopathic [medical] practice are not to be 
depended upon. A. S. 



Art. XXI. — Lectures on the Principles and Practice of Surgery. By Bransby 
B. Cooper, F. R. S., Senior Surgeon to Guy's Hospital, &c. Philadelphia, 
Blanchard & Lea, 1852 : 8vo. pp. 771. 

These lectures were originally delivered to the clinical class of Guy's Hos- 
pital, London. They are now republished, with some additions, and after a 
careful review by the author, as they at first appeared in the columns of the 
London Medical Gazette ; they do not, therefore, seem to call for any lengthened 
notice at our hands. 

Mr. Cooper disclaims, in his preface, the intention of presenting the book to 
the profession as a systematic treatise on surgery. He says, " It is not without 
mature consideration that I have determined upon publishing the present 
volume ; but I have come to the conclusion that, as its contents are of a practical 
character, embodying the experience of twenty-five years, during which time I 
have occupied the position of Surgeon to Guy's Hospital, it would be found use- 
ful, not only to the student, but also to those who have entered upon the prac- 
tice of their profession. My object has been to furnish a useful compendium 
of surgery, in which the student may meet with a clear account of the practice 
of that science, established not only on my own experience, but likewise upon 
the best acknowledged authorities." 

The chapters referring to special surgical diseases and injuries are preceded 
by several which relate to general pathology, viz. : there is one upon the blood; 
another upon the bloodvessels and absorbents ; a third upon constitutional irrita- 
tion; a fourth upon inflammation. And subsequently the topics which are 
commonly embraced in works of this kind are treated of as much in extenso as 
the limits of the volume permit, and these are unusually wide. Thus thirty 
pages are devoted to diseases of bone : twenty-three to those of joints ; fifty-six 
to fractures ; between forty and fifty to dislocations ; two hundred and sixty to 
the surgery of the different regions, &c. &c. 

From the examination which we have bestowed upon the different chapters, 
we have no hesitation in expressing the opinion that they contain much which 
will reward the consultations of the practitioner, particularly in the purely 
practical questions. For, as it were only reasonable to expect from the connec- 



1852.] 



Cooper's Lectures on Surgery. 



195 



tion which Mr. Cooper has maintained with so large a hospital as Guy's, and 
for so many years, the book is filled with the results of his personal observation 
upon almost all the affections which a surgeon can expect to meet with ; and 
numerous individual cases are cited in every chapter, to illustrate peculiarities 
of symptoms, or to enforce the propriety of a particular treatment. But in 
matters which involve the scientific rather than the practical knowledge of the 
author ; in questions of pure pathology, the book cannot be regarded as an ex- 
ponent of modern views. 

Thus, in the chapter on Diseases of the Joints, it is stated, at p. 256, in speak- 
ing of ulceration, as it is usually called, of the articular cartilage : " If the syno- 
vial membrane be the source of the altered action, the cartilage desquamates in 
the same manner as the cuticle separates from the true skin. I do not apply 
the term ulceration to this action, as the usual appearances of ulceration do not 
manifest themselves, such, for example, as the presence of vessels conveying 
red blood ; but I believe the redness in such cases proceeds from the bursting 
of the bulbous extremities of the capillaries, so that the blood is permitted to 
pass at once into the canals ordinarily receiving only those of its constituents 
which are necessary to the nutriment of the structure ; but it sometimes hap- 
pens that, under the influence of disease, the capillaries prolong themselves 
into the canals under the form of distinct bloodvessels." We need scarcely 
point out the fallacy of these opinions : the merest tyro in pathological and 
physiological studies knows that the bursting of bloodvessels gives rise to ecchy- 
mosis or other more serious hemorrhagic effusions, according to the size and 
character of the vessels ; and that the nutrition of extravascular tissues is 
effected by imbibition, without the aid of distinct canals for the transmission of 
the plasma. Again, on the same page, Mr. Cooper speaks of the points or 
patches at which the articular cartilage has been removed in consequence of 
inflammation of the articular face of the bone, as becoming filled by portions 
of synovial membrane, which are prolonged inwards, as it were, from the edges 
or circumference of the cartilage. The membrane thus abnormally present 
becomes highly vascular, and was regarded by my late colleague, Mr. Key, as 
an apparatus for the absorption of the cartilage/ 7 &c. But the more recent 
observations and experiments of Mr. Goodsir, and Dr. Redfern, have demon- 
strated the fact that the vascular membrane spoken of as appearing upon these 
points does not belong so much to the original synovial membrane, but that it 
is a new product, an adventitious fibrous tissue. And, in fact, a careful exami- 
nation of the papers of Mr. Key, published in the 18th and 19th volumes of the 
Medico- Chirurgical Transactions, will show that this author himself was aware 
of the existence of the false membrane, and admitted that the vascularity in 
question was seated in it in many of the cases examined. 

We might cite numerous other passages from different chapters of Mr. Cooper's 
volume, which would establish more generally the truth of our opinion as to 
the inaccuracy of very many of the pathological doctrines advanced or adopted 
by the author. But the limits and intention which we have assigned to our- 
selves in this notice will not admit of our longer dwelling on this point. 

The contents of this volume were originally given to the profession in oral 
lectures, a mode of committing one's self to the public which is exceedingly likely 
to involve one in numerous difficulties, unless the lecturer has complete self- 
possession and is accustomed to the duty. One of these faults is apparent in 
Mr. Cooper's lectures ; we allude to the contradictory opinions which he ex- 
presses concerning the same factor question. Thus, in the chapter on Gunshot 
Wounds, he says, at p. 96: "The wound made by the entrance of the ball is 
small, and its lips are inverted, discoloured, and valvular, while the opening 
through which the ball has made its escape is much larger, with an everted and 
ragged edge ;" while at p. 99, the following sentences occur: " Many different 
statements have been made respecting the appearance and comparative size of 
the openings made at the entrance and exit of the bullet. It has been said, that 
the hole by which it enters is smaller and cleaner than that by which it leaves 
the body, which is ragged and more gaping. This does not, however, seem to 
be correct ; the opening by which the ball enters appears to be generally some- 
what the larger of the two. But, in fact, there is so little difference between 



196 



Bibliographical Notices. 



[July, 



them that, unless the direction of the shot were previously known, it would be 
impossible to say by which opening the ball entered, or by which it left the 
body." And there are opposing statements of the same kind which we need 
not quote. Such discrepancies must have crept into the lectures without due 
reflection, and have been overlooked in the subsequent revisions which these 
underwent preparatory to their publication first in the Gazette, and subsequently 
in the present form. But though they may be acknowledged to be inadverten- 
cies, they are not the less calculated to mislead and perplex young readers, 
and therefore they constitute a blemish in the book. 

Another defect noticeable in Mr. Cooper's work, and it must be conceded to 
be a very serious one, is the frequent slurring over of important topics, and the 
omission of numerous others. This deficiency, like that just mentioned, is un- 
doubtedly to be ascribed to a want of proper method and of due reflection in the 
enunciation of his lectures, errors which subsequent revisions preparatory to 
publication should have corrected. We take as illustrations of these imper- 
fections, the following examples, almost at random from different parts of the 
book. Mr. Cooper says that the fracture of the lower portion of the radius is 
very frequent, forming almost a third of all the fractures of the bone. And 
in consideration of this circumstance, as also of the importance of the integ- 
rity of the forearm, and the necessity of a correct diagnosis and a proper treat- 
ment, it were proper to expect a somewhat detailed account of this injury in 
reference to all important points. But the whole subject is discussed, or rather 
passed over, in the most unsatisfactory and unsurgeon-like manner. We will 
quote the whole of the author's remarks with reference to it. " Fractures of 
the lower part of the radius are often misunderstood, and may be taken for in- 
complete dislocation of the wrist; but the power of restoring its normal confor- 
mation by slight force, together with the crepitus, is sufficient to distinguish 
this accident from dislocation. — The following is a case of fracture of the lower 
portion of the radius : Janet Westrook, set. 68, was pushed down in the street, 
falling forwards ; on thrusting out her hand to save herself in the fall, it came 
violently in contact with the curb-stone, the consequence being fracture of the 
radius about two inches above the styloid process. She was immediately 
brought into Guy's Hospital. The swelling being but inconsiderable, the nature 
of the accident was ascertained at once. The usual symptoms of fracture of 
the radius were all present, viz.: fixed pronation of the hand, diminished width 
of the forearm, from the approximation of the fractured extremities to the 
ulna, and the rotundity produced by the displacement of the muscles and ten- 
dons of the interosseal space. The limb was put up in the ordinary way, the 
hand being left pendent. In the course of five weeks the woman left the hos- 
pital quite recovered, and with perfect motion of the radio-ulnar articulations." 
These sentences comprise the whole of the author's observations concerning the 
symptoms and treatment of this fracture, excepting that, in speaking of treat- 
ment of fractures of the forearm, he says, "When only one bone is broken, the 
treatment does not differ from that just described, excepting that in fracture 
of the lower part of the radius, the hand should be more bent inwards towards 
the ulna, and kept in that position during the progress of the cure." 

Again, in the chapter on diseases of the bladder, inflammation of that organ 
occupies only half a page. 

Such faults as these which we have alluded to might easily have been avoid- 
ed by a surgeon of Mr. Cooper's large professional experience, and daily obser- 
vation of the deficiencies and perplexities of students, as well as of practitioners, 
whose age and position have not been so favourable to the acquisition of prac- 
tical knowledge as his own. 

But though the work does not realize the expectations which the reputation 
and advantages enjoyed by Mr. Cooper would justify, still the reader will find 
that it contains a great deal of very judicious and valuable advice concerning 
the treatment of surgical diseases. F. W. S. 



1852.] 



"Watters on Organic Life Force. 



197 



Art. XXII. — An Essay on Organic or Life Force. By J. H. Watters, A. B. 
Philadelphia, Lippincott, Grambo & Co., 1851 : 8vo. pp. 36. 

This essay was prepared as an inaugural thesis for the degree of Doctor of 
Medicine in the University of Pennsylvania. It is a production in every respect 
creditable to its author, indicating a mind adapted to close inquiry and to a 
careful investigation of the phenomena of the living organism, and of their 
causes and results, so far as these can be made the subject of observation, or 
may be inferred by cautious analogical reasoning. 

The subject of the essay is a most interesting and important one ; a correct 
appreciation of which would divest physiology of many of its present obscurities 
and apparent discrepancies, and prepare us for the study of the pathological 
conditions of the human organism with a far better prospect than has as yet 
been afforded us of arriving at a clear conception of their nature and causes, as 
well as of the means adapted for their prevention and removal. 

Discarding the once universally received doctrine of an independent vital 
principle by which organization was supposed to be produced, and which, by a 
constant control, direction, and modification of the influence exerted upon organ- 
ized matter by the several physical forces to which it is constantly subjected, 
gave rise to all the vital phenomena, from the simplest to the most complex ; 
repudiating this ancient hypothesis, and the equally untenable one by which 
the so-called nerve force is substituted for the vital principle, many modern 
physiologists have been inclined to view vitality as nothing more or less than the 
result of organized matter acted upon by the ordinary physical agents, in pre- 
cisely the same manner in which they act upon that which is unorganized — the 
difference in the effects being due entirely to the different arrangement and 
combination of the particles of matter in the two cases. 

This latter is, in substance, the doctrine advocated by the author of the essay 
before us, and he has with great acuteness adduced a series of arguments in its 
support, the force of which, if the doctrine alluded to be confined strictly to an 
explanation of the phenomena of organic life, the advocates of a living principle, 
equally with those who insist that every living act is the result of nerve-force, 
will find it extremely difficult to evade. 

"An organism," according to Dr. Watters, "is but a machine, by means of 
which the Creator takes advantage of the laws with which he has endowed mat- 
ter to effect certain objects which are the designs of God, and not of man. It 
would be of no advantage to know whether living beings were the object for 
which matter was created with its existing laws and properties, or whether there 
was no such object in the Creator's mind; and this is not a subject of investi- 
gation, though it may be of speculation. It is enough for us to know that the 
organism is a machine which acts in perfect accordance with the laws of matter, 
and is not overruled by some unknown independent agent, ' the vital principle 
that life is the necessary result when the organism is placed under the proper 
conditions ; and that this result grows out of the particular combination of the 
matter constituting it." 

The main position laid down by the author, and in support of which a number 
of cogent arguments are adduced, is " that life or the actions of an organism are 
produced hy forces which are evolved in the decomposition or decay of that organ- 
ism." The term organism being made to include the granules or germs, though 
apparently formless, from which cells are developed under proper conditions. 

" When we look/' remarks Dr. Watters, " into the organic world, it is observed 
that the natural tendency of all organic matter, under the influence of the ex- 
ternal conditions of life, is to resolve itself into simpler compounds ; but in the 
living organism there is an action directly contrary to the observed natural tend- 
ency. It was, no doubt, from this apparent reversal of the laws of matter, that 
first originated the idea of an independent agent residing in the system, whose 
office it was to overrule these laws, and give direction to vital actions. It is, no 
doubt, from this, that even to the present time, the ' vital principle' enters into 
the explanation of all vital phenomena. The attention of physiologists has been 



198 Bibliographical Notices. [July? 

almost exclusively directed to the building up of the organism. Disintegration 
has been thought worthy of attention only as it is modified by this ' vital prin- 
ciple/ or, as it makes continued nutrition necessary. As decay is common to • 
all organic matter, the attention has been diverted from this to organization, 
which is peculiar to living beings ; and nutrition is looked upon only as a means 
of ' counteracting' the 'destructive' tendency to decay, rather than as affording 
a necessary condition to continued decay. Though we cannot conceive the 
existence of a living being without change, yet this tendency to change has been 
considered destructive, rather than essential to life. It is thought that it will 
appear from what is to follow, that the arrest of the natural laws of matter in a 
living organism is more apparent than real ; that vital actions are as much the 
result of these natural laws as are death and decay ; and that death and life 
have the relation to each other of antecedent and consequent. Though death 
is so common and so natural, that we are accustomed to look upon it as a matter 
of course, yet it is no less difficult to tell why we die than why we live ; both 
are but evidences of the Creator's will. "We are constantly dying while we are 
living, and to arrest decay would be to arrest life. 

" While Dr. Carpenter ridicules the theory of a ' vital principle/ he seems 
to fall into greater difficulties than he has obviated, when he offers as his 
theory the following : The dormant vital "properties originally stamped upon 
matter capable of assimilation are developed by the very act of organization. 
He gets over the objection which would naturally arise to this theory, that 
life force must have existed prior to the act of organization, in a very sum- 
mary manner ; as also, the objection arising from the universal tendency of 
organized matter to resolve itself into simpler, rather than into more complex 
compounds. While the views contained in this article are directly opposed 
to the theory of a ' vital principle/ they are equally opposed to the theory that 
matter was originally endowed with vital properties, which are developed by the act 
of organization. These views are, that in an organism, the act of resolution 
of a complex into simpler compounds, evolves forces which give direction to 
chemical and organic actions ; and, as life is the result, the terms organic, germ, 
or life-force may be employed to indicate the resultant of these forces. This 
force is produced when the conditions of life — the germ, air, heat, and a fluid 
plasma — coexist. If the above proposition be true, life is not derived from the 
parent, but originates in the changes which take place in the germ itself. It 
has been the doctrine of some that germ-force is derived from the male parent; 
of others from the female; while others again held that it is produced by both 
parents at the same time, and by the same act that the germ is. But there are 
reasons to believe that germ-force is no more derived from either parent than 
galvanic force is derived from the individual who constructs a battery/ 7 

The first series of arguments advanced by Dr. W. in support of his general 
position are, to show that, according to the universal law of chemical action, the 
properties of an organism could not be developed except by disorganization ; 
that when it is said that forces are evolved by the decay or oxidation of the 
organism, entirely distinct from the chemical compounds that result, nothing 
is assumed which is not exemplified in every chemical action which takes place, 
whether in the organic or inorganic world; and, to point out the fact that in 
organic chemistry, oxidation evolves a force which produces deoxidation ; and 
thus to show, if possible, that disorganization, that is the oxidation of the organ- 
ism, may evolve forces which produce organization. 

"Wherever there is life/' urges the author, "there is decay, and in health, 
decay is always in proportion to the vital activity. This shows some necessary 
connection between the two, and a possibility that there may be some truth in 
the foregoing proposition. It may be said, if the proposition be true, there 
should be life wherever there is decay. But not so ; if an acid be thrown upon 
zinc, oxidation takes place, but there are no electrical phenomena unless there 
be a peculiar arrangement of the zinc with another metal; so it is only under a 
peculiar arrangement, as in an organized structure, that decomposition and decay 
give rise to vital phenomena. 

" There is no fact better established in physiology than, in the exercise of the 
animal functions, the destruction of the organ is directly in proportion to the 



1852.] 



Watters on Organic Life Force. 



199 



activity of the functions. There can be no doubt but the final cause of the ex- 
ercise of organic functions in animals is, so far as the individual is concerned, 
to supply and keep up the conditions for the exercise of the animal functions. 
Yet it is no less true in animals than in plants, that the exercise of organic func- 
tions in them is also attended with decomposition and decay in proportion to 
their activity. In the young, the tissues are soft, and decay is rapid, and the 
vital actions are correspondingly active ; while in the old the tissues become 
more firm and permanent, and the vital actions are consequently less vigorous. 
In the former, the repair of injuries is rapid, and if the cause of disease be re- 
moved, the restoration to health is quick and entire ; but in the latter, the struc- 
ture is firm, decay is slow, the vital energies are correspondingly low, and if 
there be a restoration, it is tedious and often but partial. From the beginning 
of life to the end of it, there is a constant relation between decay and life action. 
It has been considered that decomposition of the muscular and nervous tissues 
results from their functional activity : if the proposition here advocated be cor- 
rect, their functional activity results from decomposition and decay, or from 
forces evolved in this process. A machine of art acts more easily and with less 
friction when composed of a hard material ; while in the organism, as the tissues 
become more firm the actions are less; hence this must be because there is less 
force to produce the actions ; but there is a constant relation between the decay 
and the actions of an organism ; hence it would follow that the destruction does 
not result from the action, but the action from the forces evolved in its oxida- 
tion. The relation preserved in health between decay and renewal is so con- 
stant that it cannot be believed a mere accident. As decay and renewal are 
directly opposite to each other, they cannot be dependent upon the same cause ; 
hence, as the relation is so constantly preserved, the one must be dependent upon 
some condition afforded by the other. Now, as the natural tendency of the 
organism is to decay, and, as there ceuld not be renewal previously to decay, it 
is most probable that decay affords the necessary conditions to renewal ; that is, 
the very act which creates a necessity for renewal, also evolves the forces neces- 
sary for its accomplishment. 

"The above proposition seems somewhat plausible, when we consider that 
the same conditions which are necessary to decomposition and decay, are 
conditions necessary to life. Under the very same circumstances we have 
life manifested in one organic compound, and nothing but destruction in ano- 
ther ; while, without these circumstances, there is neither life nor destruction 
in either. Can this be because air, heat, and moisture are conscious exist- 
ences, and have not the same tendency in the two cases? Can it be that 
they have in the one case a deadly, while in the other a vitalizing influence? 
It would seem not; although vital actions do result from the influence of these 
conditions in the one case, yet it would appear that this can only be effected 
through decay ; for their tendency to destroy and disorganize must be the 
only way through which they exert their influence throughout the organic 
world. Take a seed, for instance; if it be preserved from the conditions of 
decay, it will remain unchanged for any length of time; but so soon as the 
influence of these conditions operates, life is manifested — an act of organiza- 
tion, which is directly contrary to the admitted natural influence of these 
conditions. It is not an object here to define the forces which produce vital 
action ; admit if you please the existence of an independent ' vital principle ;' 
or if you would rather admit that £ matter capable of assimilation was origi- 
nally endowed with vital properties or let there be any hypothesis which 
may enter into the heart of man to conjecture, the argument is the same ; that 
the forces which produce vital actions, be they what they may, are developed 
by means of the oxidation or decay of the organism, just as electricity, heat, 
and light are evolved by the oxidation of zinc. As the external conditions 
of life are the same as those of decay, the different results must proceed 
from difference in the substances acted upon ; and as the tendency of these 
conditions is to produce disorganization rather than organization in all organic 
compounds, and as there is decay wherever there is life, decay must be a neces- 
sary antecedent to life. But an organized structure is so arranged by an Infinite 
Wisdom, that in it the very act of incipient destruction liberates a recuperative 



200 



Bibliographical Notices. 



life-force, which, if there be a supply of nutriment, renews and builds up the 
structure, every particle of which is, in its turn, destined to decay, and thus acts 
its part to keep up the actions of the individual." 

It is not our intention to follow our author through the various arguments he 
presents in support of his position — that vital actions are produced in an organ- 
ism by forces which are evolved in the decomposition or decay of that organism 
— a mere synopsis of them would not give to our readers a correct idea of their 
full force and bearing. All that we desire is to furnish a general idea of the 
views advocated in the essay before us, and of the manner in which their truth 
is endeavoured to be sustained. 

In treating of the condition of a seed before germination, Dr. W. remarks : — 

"The phrase ' dormant vitality' is the received explanation at the present 
time ; but I have attempted to show that there can be no such thing as dormant 
vitality, and, moreover, if there could, that the external agents could not stimu- 
late it into action. It is contended that if there be forces in the seed, and there 
must be, these forces must be in action, though they may not produce action ; 
and that the only way air, heat, and moisture, or any other agents, can produce 
action in the seed, is either by their additional force or by changing the direc- 
tion of the existing forces, and thus disturbing the balance. The facts in the 
case are simply these: A seed maybe preserved any length of time without 
undergoing the slightest change; but, when certain external agents are applied, 
life becomes manifest. The object is to interpret these phenomena, just as we 
would those which present themselves in any artificial experiment. This expe- 
riment, performed for us by nature, is brought forward in support of the propo- 
sition — that life action is produced by forces, which are evolved, or take a new 
direction, in the decomposition of the organism. The seed does not possess vitality, 
in any sense of the word, before germination ; it does not even possess life-force, 
either dormant or in action, for life is only produced when it is under the influ- 
ence of certain external agents, and, therefore, life-force is the resultant of 
forces as directed by the seed under the influence of these external agents. 
Therefore, we have life-force only under the cooperation of all the conditions 
of life ; but its components have existed and been in operation since the founda- 
tion of the world, or the creation of matter. Now these components are not 
mysterious agents which never manifest themselves except in organized struc- 
tures; but the very same forces which produce the ordinary chemical actions, 
when directed by an organism under the influence of these external agents, 
become the components of life-force. But organization must be produced by 
means of disorganization, because the natural tendency of an organized struc- 
ture, under the influence of the external conditions of life, is to disorganization ; 
and consequently, organization cannot be directly produced by the ordinary 
forces. But, as no means or ingenuity whatever could make gravitation directly 
elevate a weight, yet, as has been seen in the case of the inclined plane, it may 
be made to do so indirectly, by means of depressing a weight, which is its natural 
tendency; so no fortuitous circumstance or event could ever make the ordinary 
forces of matter directly produce organization, yet they may produce organiza- 
tion indirectly by means of disorganization, which is their natural tendency. 
From the foregoing considerations, therefore, it is concluded that life originates 
when the seed is placed under the proper conditions, through decay or oxida- 
tion, which these conditions naturally induce." 

Hybernation the author believes capable of an easy and natural explanation, 
upon the supposition that life is produced by forces which are evolved in the 
act of decay. 

"As the temperature, which is a condition to decay, diminishes, decay must 
also diminish ; and as the decay of an organism is the means by which life-force is 
produced, the diminution of decay would diminish life-force accordingly. If the 
temperature be so much diminished as to arrest decay, life must consequently 
cease ; not in part, but entirely. This state of death may continue indefinitely, 
so long as the external conditions are preserved. But with the return of heat, 
if the structure have not been destroyed, decay, and consequently life, com- 
mence again as in the original germ; and, whereas the animal was dead, it is 
alive again." 



1852.] 



"Waiters on Organic Life Force. 



201 



With the view of placing before our readers the manner in which Dr. W. ap- 
plies his doctrine of the development of life-force to the explanation of the origin 
of organization, we shall extract the greater portion of his remarks on the sub- 
ject of Equivocal Generation. Although the quotation is a long one, it will, we 
are persuaded, interest, and we hope instruct, all who will take the trouble to 
peruse it. 

" Observation," says Dr. "VV., " has tended to establish this mode of genera- 
tion, but it has been rejected upon theoretical views. Those who deny this 
mode, say, although the entozoa have no prototype in nature, yet germs taken 
into the system produce different animals, on account of the peculiar circum- 
stances of their position. This is begging the question ; for this is itself 
equivocal generation. That a germ is necessary to life is admitted and pre- 
supposed in the theory of equivocal generation ; yet it has been accustomed to 
be considered equally absurd with spontaneous generation. Reasoning, a priori, 
from the proposition that life is produced by the decay of an organized struc- 
ture in the presence of a fluid plasma, we are led to suspect this mode of gene- 
ration, though there might be an inclination, at first, to confine it to plants and 
animals, consisting of a single, or a very few cells. But when it is considered 
that all animals and plants are made up of cells, and that the growth of the 
individual consists in the growth and reproduction, or multiplication of cells, 
our original suspicion might be somewhat extended. If it be true that the 
organism is not endowed with any vital principle, or force distinct from its 
own structure, then nutrition and generation — both equivocal and what is 
called regular — are involved in no greater mysteries than the ordinary chemical 
actions; but, upon the theory that there is a germ-force distinct from the forces 
derived from the matter constituting the germ, then, both regular and equivocal 
generation are equally inexplicable ; for they both seem directly opposed to this 
theory. Admit it true, for a moment, that the germ derives a certain amount 
of life-force from its parents ; now a force cannot increase of itself, and, if life- 
force increase with the growth of the individual from the germ, upon what 
does it feed? The quantity of matter of the body may be increased by addi- 
tional matter taken in; so, if the force increase, it must be by additional force ; 
but life-force does increase, else reproduction would involve the death of the 
parent. Now, if life-force be something peculiar and distinct from the forces 
of the matter that constitutes the organism, whence does the individual derive 
this additional force ? The natural inference is, that it is not distinct, and is 
derived from the additional matter that becomes organized ; and if the addi- 
tional force be thus derived, why not the original force of the germ also ? 
Hence, the very fact that there is reproduction in any mode whatever, is a 
strong argument in support of the idea that there is no agent at work in the 
organism distinct from the agents which produce the ordinary chemical actions ; 
that it is the organism itself that makes the distinction. If it be the inde- 
pendent vital principle that determines the species and its constancy, there 
could be no deviation from the original type, for an offspring could not have 
a different vital principle from that which its parent had, and consequently, 
could not transmit one different from that which it received." 

"In considering the above views of reproduction, it would be well first to 
notice some examples where each generation possesses a distinct individuality, 
while it is, at the same time, entirely different from that which preceded it — 
examples where every third, fourth, or fifth, or even tenth generation only, 
resemble each other, while each generation is distinct and independent. The 
development of the distoma from the egg is a good instance to illustrate this 
point. An animal is developed from the egg, named the grand-nurse. This 
animal gives birth to numerous other animals dissimilar to itself ; these are 
called the nurses. These, in their turn, give birth to other animals not in the 
least resembling the generations preceding ; these are the Cercariai. The cer- 
caria is metamorphosed into a distoma, and now, for the first time, we have 
an animal resembling those that produced the original eggs. Among the 
Aphides, it is only after eight or ten generations from the egg, that the perfect 
animal appears with the distinctions of sex. These examples are sufficient to 



202 



Bibliographical Notices. 



[July, 



illustrate the position, that the development of an animal from the egg is pro- 
gressive — that the perfect state is arrived at, sometimes at least, through the 
successive steps of equivocal generations. Various inferences are deducible 
from these facts, in reference to the subject before us. The first is, that there 
may be reproduction without the union of the sexes. It is true, some have 
supposed that there was a superabundance of sperm in the original egg ; that 
this, being taken up by the young animal, vivified germs produced by it; that 
the superabundance still existing, being taken up by these young animals, 
was similarly appropriated in the production of their young, and so on, for 
many generations. But this only shows how facts are twisted to reconcile 
them with theories. The simple facts would seem to indicate that there was 
no spermatic influence except in the original egg ; that the grand-nurse itself 
affords conditions for the origin of the nurses ; and that the nurse itself gives 
origin to the germs of cercarise ; that the distoma is developed from the cer- 
earia ; and that the union of the sexes in this state gives origin to the eggs. 
Again, upon the theory of a peculiar vital agent, there could have been but one 
in the egg ; say this produces the grand-nurse, if you please ; now the grand- 
nurse, possessing but one vital agent, gives birth to an immense number of 
nurses, of course, each possessing an independent vital agent ; now, each one 
of these nurses, possessing but one vital agent, gives birth to an immense 
number of cercariee, of course, each possessing an independent vital agent. 
Also, the more complex animals are composed of an innumerable number 
of cells or organisms, which are only dependent for their action upon those 
external conditions which life action in general is ; but the original germ, from 
which the cells composing the complex animal were developed, could have 
possessed but one vital principle. The important question here is, where did 
all these independent vital principles come from ? They could not be produced 
by the subdivision of the original one in the egg or germ-cell, supposing such 
a thing possible; for each successive generation is carried to a higher state of 
development than the former, which could not be the effect of a part of a vital 
principle. But suppose, for a moment, that a vital agent does exist in each of 
the cercarias which are finally developed from a single egg, that they do origin- 
ate in some way, no difference how; all these must be of the same kind, at 
least, as the one which developed the grand-nurse from the egg ; for, if it were 
admitted possible for the vital principle to multiply indefinitely, it would still 
seem impossible that it should change its character. So, admitting the exist- 
ence of a vital principle, it is necessary to admit also, that the peculiarity of 
the individual is not dependent upon it, but upon the peculiar organization of 
the germ itself; for, if the same agent produces at one time a grand-nurse, then 
a nurse, and then a cercaria, animals entirely different, the difference must 
necessarily result from the peculiarities of the material acted upon. Hence, 
though all animals have a single cell for their common origin, yet the pecu- 
liarities in the structure of the future animal, are entirely dependent upon 
peculiarities in the composition of the germ itself. The constancy of species, 
therefore, is not dependent upon the vital principle, admitting one to exist, but 
upon the constitution of the germ itself. Hence, the dumb agents which pro- 
duce the ordinary chemical actions, when directed by the germ, could produce 
all the vital actions as well as an intelligent vital principle, if the exercise of 
intelligence is unnecessary. 

" But it may be objected that the foregoing argument is irrelevant ; for, we 
do not know the nature of the vital principle, and, therefore, should not argue 
upon it as if it were analogous to an}-thing we do know. This objection would 
put a stop to all investigation ; for it is always necessary to reason from the 
known to the unknown. Whatever it may be which produces life, it certainly 
does not only resist decay, but produces actual organization ; therefore, it is a 
force. If it be a force, it must possess all the properties of force in general, and 
must be reasoned upon accordingly. As force cannot be created or destroyed, 
life-force, therefore, is but a peculiar combination of forces which have existed 
since the creation, as organized matter is but a peculiar combination of matter 
which has existed since the creation. 

" Perhaps it would be well now to notice the development of vertebrate ani- 



1852.] 



"Watters on Organic Life Force. 



203 



mals, and see what analogy exists between their steps towards maturity, and 
those of the distoina and aphides just considered. First, notice the formation 
of the germ itself. In the evolution of the spermatozoa, suppose that the 
* parent-cells' are evolved immediately from granules which are secreted by the 
tubuli seminiferi ; these parent-cells give birth to the 'vesicles of evolution/ and 
die themselves ; the ' vesicles of evolution' give birth to the spermatozoa and 
die themselves. Thus, the development of spermatozoa from granules secreted 
by the tubuli seminiferi is precisely similar to the development of the distoma 
from the egg. The evolution of the ovum from the ovisac is the same. It is 
the received opinion that the germ-cell is formed by the union of the sperma- 
tozoa with the ovum. While this union gives origin to the germ of a new 
being, independent vitality existed prior to it, as is indicated by the evolution 
of the spermatozoa and the ovum. All this is just what would be expected, if 
we admit the proposition that life-force is the resultant of the ordinary forces of 
matter as they are directed in the decay of the organism. But our observations 
must not stop here ; we now have the ' germ' of a new being. All animals and 
plants have their origin in a single cell. This germ-cell is not a miniature of 
the future animal ; it has not a backbone with a spinal cord having a ganglionic 
expansion ; it has not an alimentary canal, liver, kidneys, and a pulsating 
heart; it has not muscular and nervous tissues with organs of locomotion. 
Yet it is all that the parents contribute to the production of a new being, 
which, after a long series of progressive steps, acquires all the peculiarities of 
its species, having all the organs necessary to organic and animal life. The 
diversified cells which compose the various tissues and organs of the fully- 
formed animal, must be produced by equivocal generation, as they did not 
exist in the germ. While the animal, through its various changes, maintains 
its distinct individuality, its elementary structure is undergoing the changes 
of equivocal generation, just as if, in the evolution of the distoma, the ' nurses' 
should not separate, but continue together so far as to constitute but one indi- 
vidual, and the cercaria?, to which these ' nurses' give birth, should continue in 
the same individual and constitute part of its structure. Thus, the animal 
would undergo various metamorphoses ; but would not at any time lose its 
individuality. So far as observation has gone, it tends to establish the view here 
taken ; that the various changes which the embryo undergoes in its develop- 
ment, are due to equivocal generation of cells constituting it. An animal is a 
compound organism made up of tissues which are composed of cells. The 
animal, therefore, would change with the cells ; these cells are very diversified 
in the fully-formed animal, but they all originated in a single germ-cell. Now 
each cell which enters into the composition of the most complex structure, is 
an independent organism as much as if it were separate ; its actions are only 
dependent upon the same conditions that life action in general is. It is plain, 
therefore, that it is just as reasonable a priori, that the various cells composing 
a fully-formed animal should be evolved by equivocal generation, starting from 
the germ-cell, as that the distoma should be evolved by equivocal generation, 
starting from the egg; and, if we reject the theory of a peculiar vital agent, 
there is nothing, cl priori, against either. The original germ only affords 
conditions for the first act; that act of the germ*affords conditions for the nest, 
and so on continually ; so that there is a continual progression from the original 
cell to the fully-formed animal, each act affording the conditions for the next: 
'the present is the offspring of the past and the germ of the future ;' break one 
link in the chain, and the whole machinery is destroyed. Metamorphosis, 
therefore, is only the change of form which the individual undergoes on account 
of its elementary structure being changed by equivocal generation. 

" If the above view be true, it is evident that the material determines the farm 
as well as the vital actions. The material is all that the parents contribute to 
the production of the germ, and, consequently, to the production of a new being. 
Yitality does not originate with the germ-cell. The germ-cell is the effect of 
vital action : and vital action too entirely independent of the parents. The 
epithelial-cells of the tubuli seminiferi are part of the parent, but the material 
which they secrete is independent; and, though in this condition it appears 
formless, and does not show any sign of life, yet this is all the parent contributes 



204 



Bibliographical Notices. 



in reproduction. The changes which take place after are entirely independent 
of the parent. When this secretion is under the influence of proper conditions, 
the ' parent-cells' appear which commenced with the change of material pro-- 
duced by these conditions ; the forces thus evolved carry the interior to a higher 
state of organization. When this material thus prepared is under the same 
influences, life action and cell growth commence in it; and ' vesicles of evolu- 
tion' are produced. These prepare the material from which the spermatozoa 
are developed. The spermatozoa and the germinal vesicle of the female mingle 
their contents, which material is the foundation of a new being. This view is 
confirmed, not only by the fact that the ova of some animals are fecundated 
after their expulsion from the body, but also by the fact that the spermatozoa 
of some animals are developed after the ejection of the seminal fluid. A good 
illustration is also found in the development of epithelium-cells from a formless 
material — the basement-membrane. It is true cells are sometimes partially 
developed within other cells, but the parent-cells only furnished the material 
or germs and a nidus for their early development, as the womb of the mammal 
only furnishes a convenient place for the early development of its young. 

" But not only is reproduction accomplished by means of equivocal generation, 
but it would seem that nutrition is also. Formerly, all actions which take place 
in the system were referred to the vital principle to the exclusion of chemistry ; 
now, certain actions, such as digestion, are found to be chemical, and straight- 
way their vitality is denied. Vitality is not incompatible with chemistry, and 
why may not the same action be both vital and chemical? An action is no less 
chemical because it takes place in the body ; it is no less vital because it can 
take place out of the body, when those conditions which are supplied in the 
body are supplied out of it. Digestion is now considered purely chemical ; this 
does not prove that it is not at the same time purely vital. If the proposition 
be true, that vital actions are produced by forces which produce the ordinary 
chemical actions, as they are directed in the decay of an organism, all vital actions 
are purely chemical actions. As the same force which gives motion to ma- 
chinery of man's construction, as the water-wheel, the clock, &c, in the hands 
of the Almighty causes the apple to fall to the earth, and regulates the planets 
in their orbits ; so, the same forces which cause the ordinary chemical actions, 
in the laboratory of Nature, give life to the lichen, rear the gigantic oak, and 
build up the wonderful structure of man. 

" It is not contended here that in nutrition each new cell is not, as a general 
thing, similar to the one whose place it supplies in the tissue, more than it 
would be that the offspring is not similar to its parents. But this is the goal 
of assimilation arrived at by successive alternate or equivocal generations, 
starting from certain nitrogenized compounds or germs in the alimentary canal 
and lymphatic system ; just as an independent individual, similar to its parents, 
is the goal of reproduction arrived at through successive alternate generations, 
starting universally from a single germ-cell. When air, heat, and. moisture are 
applied to a seed, decay commences, life-force is produced, and germination is 
the natural consequence. If a seed be ground to powder, and air, heat, and 
moisture applied, each separate particle of the germ, in its decay, would evolve 
life-force as much as if the seed had been left entire — as is observed in fer- 
mentation ; but, as the force of all the granules is not concentrated as it would 
be in the perfect seed, there is not produced an individual plant similar to the 
one which produced the seed. As the formless material secreted by the epi- 
thelial-cells of the tubuli seminiferi, contains germs of cells from which are 
evolved, by equivocal generation, the spermatozoa ; so, the formless material 
secreted by the glands emptying into the alimentary canal, contains germs of 
cells which commence the wonderful process of converting an aplastic into a 
plastic material. The fact that digestion can take place out of the body when 
the gastric juice is furnished, is no argument against its being a vital action, 
fur the conditions of life^ve a germ, a fluid-plasma, air, and heat, and it matters 
nothing how these may be furnished. If it were possible to supply all the con- 
ditions artificially, life would result no less than if supplied by nature ; but, as 
the natural tendency is to decay, and life is produced by the decay of an 
organism, the germ cannot be produced except by a previously existing organ- 



1852.] 



Wilson on Syphilis and Syphilitic Eruptions. 



205 



ism. If the germs be furnished by nature and the other conditions by art, the 
actions which follow would be the same as if all were furnished by nature. 
Therefore the fact that the gastric juice will dissolve food out of the body, does 
not prove it not a vital action ; though, if our proposition be true, it is chemical 
also, as well as all other vital actions. Coagulable lymph is effused in a fluid 
state ; soon cells begin to be formed, and after a time they are united and form 
a solid tissue ; so the secretions which are discharged into the alimentary canal 
would be expected to be fluid, though they contain germs needing only proper 
conditions to be speedily developed into cells. These cells are not similar to 
the epithelial-cells which produced the germs, therefore they are equivocally 
generated, as are the epithelial-cells themselves ; for they are not produced by 
epithelial-cells, since the basement-membrane has a different origin. Thus the 
process of nutrition, as well as reproduction, commences from germs secreted 
by epithelial-cells, and is a process of equivocal generation." 

From the foregoing extracts, some idea will be derived of the doctrine of 
organic or life-force advocated by Dr. Watters, and of the general scope of 
the arguments by which that doctrine is enforced. Many views of a highly 
interesting character are presented by him, either arising out of his leading 
proposition, or adduced as additional evidence of its correctness, which we 
have not noticed ; the true value of these cannot, in fact, be well appreciated, 
excepting they be studied in the order and connection in which they occur in 
the essay before us. To such of our readers as feel an interest in one of the 
most obscure questions in physiology, we recommend a careful perusal of the 
entire essay, which we understand is for sale by the publishers. Dr. Watters 
has, we believe, pointed out the leading proposition that, in its more full deve- 
lopment, will be acknowledged to constitute the true doctrine of vitality. 

That the doctrine, as presented by our author, is unattended with difficulties, 
we are not prepared to admit. We feel inclined to object even to the terms in 
which his leading proposition is expressed. Without denying that life or the 
actions of an organism, are the result of forces evolved in the reciprocal action 
upon each other of the materials entering into the composition of the organism ; 
that this reciprocal action is precisely the same as takes place in inorganic 
matter; that the one form of matter is subjected to no influences from which 
the other is abstracted ; — without denying that the difference in the phenomena 
produced in the two cases is solely dependent upon the particular arrangement 
and combination in which matter is present in the organic state, and the ab- 
sence of that arrangement and combination in its inorganic condition ; — admit- 
ting also that its capacity for the development of life-force may be destroyed by 
the change produced in organic matter from the reciprocal action upon each other 
of its constituents — by their chemical change, if you please — it must be evident 
that this decomposition or decay of the organism is as much an effect of the 
actions by which life-forces are supposed to be evolved, as are those forces them- 
selves. Hence we conceive it to be incorrect to say that the latter are evolved 
in or by the decomposing or decay of the organism, both being equally effects 
of the changes that take place in the condition of the matter constituting the 
organism. 

The form of expression made use of by the author is, in fact, often defective, 
even where the idea intended to be conveyed by him has all the characteristics 
of truth. D. F. C. 



Art. XXIII. — On Syphilis, Constitutional and Hereditary; and on Syphilitic 
Eruptions. By Erasmus Wilson, F. E. S. London, 1852 : 8vo. pp. 235. 

The subject of syphilis has attracted attention in proportion to its diffusion 
and importance. Since Mr. Hunter devoted his rare powers of observation and 
generalization to its elucidation, the disease has been most zealously and suc- 
cessfully investigated by a host of able men ; so that the modern literature of 
this speciality is now quite as extensive as that of any other. There are several 
No. XLVIL— July, 1852. 14 



206 



Bibliographical Notices. 



[July, 



points, however, which are still more or less obscure ; and to some of these Mr. 
Wilson, with whose scientific attainments and general qualifications for conduct- 
ing such studies our readers are all familiar, has devoted a portion of his time.- 
The peculiar effects of constitutional syphilis, as manifested in the development 
of cutaneous eruptions, have occupied the larger part of his attention. 

We shall give a brief sketch of the contents of the volume. 

The first chapter considers the characters and peculiarities of the syphilitic 
poison. 

The common mode of transmission of the poison, the author remarks, is through 
the agency of a morbid secretion poured out upon the surface of a syphilitic 
sore : this secretion being saturated with the poison. An abraded surface 
presents, of course, the most favourable conditions for rapid and certain con- 
tamination ; but, as Mr. Ceely has demonstrated with regard to the vaccine 
virus, such an abrasion is by no means necessary, the poison of syphilis as 
well as of the vaccine disease being capable of being absorbed from an unbroken 
surface, provided it be retained upon it a sufficient length of time, and in a 
sufficiently moist state. 

Mr. Wilson contends that there is still another method by which syphilis may 
be, and often is communicated to a previously healthy person : " It is that in 
which a man or a woman having been contaminated by the poison, and having 
been, to all appearance, cured of the consequent disease, has, nevertheless, 
become so saturated with the virus, as to possess the property of communicating 
syphilis to a sound person, by means of his secretions. This mode of trans- 
mission is so important that I will proceed to illustrate it by means of cases 
which have fallen under my observation (p. 3.) One of these cases will serve as 
an example. We will take the first. A gentleman had a small venereal sore 
on the prepuce, in the month of November ; it got well speedily. In the suc- 
ceeding February, he had sore-throat and rheumatic pains, slight in character. 
In March, he married. In the following June, a furuncular abscess appeared 
upon the upper and inner part of one of the thighs of the wife, which left an 
exceedingly obstinate sore ; moreover, a rash showed itself upon the skin. 
These symptoms, under a modified treatment, disappeared ; but subsequently a 
few pimples broke out upon her body ; she had a feeling of soreness in her throat, 
but without congestion ; her skin was muddy and discoloured ; and her husband 
had an attack of iritis. The furuncular abscess, Mr. Wilson considered as of 
the common kind ; but its indisposition to heal, and the breaking out of the 
eruptions, he attributes to the contamination of the wife's system by absorption 
from the syphilis-tainted urethral or seminal secretions of the husband. He 
remarks also in connection with another case, " The question of the liability of 
a healthy woman to become infected with syphilis by a nurse-child, I hold to be 
a fact beyond the reach of doubt." The instance which he cites to prove this is, 
undoubtedly, as strong a one, apparently, as could be presented. But it may 
be fairly objected to the validity of the first case, that we have no assurance that 
the husband had not a chancre, at the time of his marriage, which was capable 
of communicating the disease to his wife ; and the only evidence as to the immu- 
nity from syphilis, primary as well as secondary, of the two women who acted 
as nurses, in turn, to the child, in the second instance alluded to, is the assur- 
ance by the physician who reports the case, that they were respectable married 
women, and that the husband of one of them " was perfectly free from any trace 
of venereal disease." The nature and accuracy of the examination instituted 
by the physician to place this fact beyond suspicion are not mentioned. Now, 
it would have been very easy, and much more satisfactory for the argument's 
sake, for Mr. Wilson to have tested by direct inoculation, whether the secretions 
from the skin and other parts of persons suffering under constitutional syphilis, 
are really capable of inducing the disease. But the author has recorded no such 
experiments ; indeed, he says that, "No experiments in the world can shake the 
force of the conclusions' 7 which he derives from the cases which he records, and 
others like them : (p. 14.) We do not think that these are by any means conclu- 
sive ; they are all open to the grave suspicion that primary symptoms existed 
at the very time, and cannot be admitted to set aside the rigid analysis and the 
positive experiments of John Hunter, Ricord, and other intermediate investi- 



1852.] Wilson on Syphilis and Syphilitic Eruptions. 



207 



gators, which have made it almost, if not wholly, a matter of demonstration, 
that constitutional syphilis is not contagious. 

It is well known that many surgeons admit that gonorrhoea may give rise to 
secondary symptoms. According to Ricord and his disciples, this can only 
occur when there is a chancre at some point which permits its specific secretion 
to mingle with that of the inflamed mucous membrane. But Mr. Wilson ex- 
plains the phenomenon upon the ground of the contagiousness of constitutional 
syphilis. He says (p. 19), "The recognition of the contagion of constitutional 
syphilis, a fact too obvious to admit of a moment's hesitation, will go far to ex- 
plain a circumstance which must have fallen under the observation of every 
unprejudiced investigator of the syphilitic poison and its manifestations, name- 
ly, the occurrence of syphilitic eruptions and other symptoms of constitutional 
syphilis after gonorrhoea. When we see a man perfectly free from any primary 
symptoms of disease, communicating syphilis to his newly-married wife, by his 
secretions alone, can we doubt the possibility of a similar result accruing from 
a syphilitic secretion poured out by the mucous membrane, as happens in gonor- 
rhoea? I do not say that every gonorrhoea is syphilitic ; on the contrary, I 
know that few are so, but those few have as much the power of transmitting 
syphilis as an undoubted chancre. " And, in continuation, he gives the case 
of " a medical man who had gonorrhoea, but neither excoriation nor sore:" 
after exposure to great inclemency of the weather, however, he was attacked 
with rheumatic fever, eruption on the skin, and iritis. Ten years afterwards, 
he again suffered from gonorrhoea ; and subsequently another series of consti- 
tutional symptoms appeared. Yet, notwithstanding the ease with which cer- 
tainty might have been arrived at in this case, viz. by the inoculation of some 
of the gonorrhceal discharge, and only by this process, this mode of diagnosis 
is neglected, and the nature of the local affection is permitted to rest upon the 
assurance of the medical man, " that he felt convinced that he could not have 
had a chancre in the urethra." If the secretions in constitutional syphilis are 
to be considered as possessing contagious properties, then, as Mr. Hunter argues, 
much more must the blood be regarded as poisonous ; and consequently, " no 
person that has this matter circulating, or has the lues venerea, could escape 
having a venereal sore whenever he is bled or receives a scratch with a pin, 
the parts so wounded turning into a chancre." (Palmer's ed. of Hunter's Works, 
Philad. vol. ii. p. 239.) 

In the second chapter on " primary syphilis," the views entertained by the 
most authoritative writers are adopted, and briefly stated. With regard to the 
much discussed question, as to the cause and nature of the specific induration 
of chancre, Mr. Wilson is of the opinion that this condition "is itself a mani- 
festation of constitutional action ; in other words, the induration is a constitu- 
tional affection superadded to the primary disease." p. 27. This view coincides 
with that which is so well advocated by Ricord in his Lettres sur la Syphilis, 
Paris, 1851, 19th letter, in which he says that the indurated chancre is to syphi- 
lis what the true variolous pustule is to variola ; what the genuine vaccine 
pustule is to vaccinia ; the evidence, namely, of constitutional implication. 
And he further states that, "as a general ride, a patient who has once had an 
indurated chancre, never has another." 

In the third chapter, the author points out the analogies and the differences 
between the peculiar form of fever, or constitutional reaction, which follows 
upon the introduction of the syphilitic virus into the system, and the exanthe- 
matous fevers. He considers that " this inflammatory movement, or syphilitic 
fever, is a sign of the accumulation of the poison within the blood, to such a 
degree as to disturb the healthy functions of the body, and is attended with 
symptoms which indicate derangement of the nervous, vascular, and digestive 
systems, and especially of those surfaces of the body through which it is possi- 
ble for elimination to occur: " (p. 30.) 

But numerous as are the points of resemblance between the syphilitic and 
the exanthematic poisons, in their respective manifestations upon the system, 
the differences are even more striking. And these discrepancies Mr. Wilson 
ascribes to a radical difference in the nature of the poison. The virus of measles, 
scarlatina, and smallpox, originates in conditions extraneous to the system ; 



208 



Bibliographical Notices. 



it reaches the blood as an agent foreign to its nature, and immediately upon 
attaining the point of saturation it excites an explosive effort for its elimination, 
under certain regular laws of sequence and time ; and after the poison has once ■ 
been entirely thrown off, the system usually enjoys an exemption from subse- 
quent contamination. The syphilitic materies morbi, on the other hand, originates 
within the body, and " is probably little more than a modification of the na- 
tural secretions ; it is consequently less irritant in its nature, and it tends to 
assimilate with the blood ; and with the tissues, rather than to excite an action 
which may result in its removal. Hence the poison is slow in accumulating, its 
excitation of febrile symptoms seems rather a matter of accident than the conse- 
quence of an irresistible law ; the patient enjoys no immunity from a recurrence 
of the morbid action, and the poison is only partially removed by the febrile 
effort:" (p. 34.) \ 

In the succeeding hundred pages, the progress of the disease is studied and 
explained in accordance with this view, its different phases being regarded more 
or less in the light of so many efforts made to rid the system of its implacable 
and murderous invader. Accordingly the various forms of the diffused cutane- 
ous eruptions are described, as well as the more local implications of special 
parts or tissues. 

The peculiarity of Mr. Wilson's views appears, if we understand him aright, 
to consist in his explaining all the seemingly varied eruptions by virtue of a 
mere modification in the form and degree of the congestion of the skin. Thus 
he says that the syphilodermata present two principal forms, the one being sim- 
ply congestive and unattended with elevation of the skin ; the other presenting 
an obvious elevation. To the former group belong roseola, the maculge, and 
erythema ; to the latter the papulae of lichen, and the tuberculae. But these 
differences, he admits, are more apparent than real, and may be looked upon 
as stages of development of the same disease. Roseola, by an easy gradation, 
is converted into lichen, or tubercular syphilis, and these latter, by simple sub- 
sidence, become syphilitic maculae. His classification of the eruptions is very 
simple, these being only three in number: " 1, simple congestion of the skin, 
constituting Roseola and Erythema; 2, congestion, with elevation of separate 
follicles, constituting Lichen; and 3, congestion, with elevation of a small 
group of follicles, or uniform tumefaction of a small portion of skin, exceeding 
two lines in diameter, constituting Tubercula. These may be considered as 
typical examples of cutaneous syphilis ; and all the numberless modifications 
which are met with in practice may be referred to one or the other of the above 
three heads:" (p. 42.) 

We shall not enumerate all the subdivisions, although they are not very nu- 
merous. They are amply described in the text, and illustrated both by numerous 
cases and by beautiful drawings. Thus it will be seen that the diagnosis of the 
syphilides is materially simplified by the author. Whether he is right or not, 
we do not pretend to say ; but his thorough investigations into the anatomical 
and physiological peculiarities of the skin, certainly give great weight to his 
opinions, and incline us to adopt his views. 

The chapter on Congenital, and Hereditary Syphilis, are exceedingly interest- 
ing, in some respects, and are amply illustrated by examples from the author's 
clinical experience. He seems firmly impressed with the conviction, from his 
large observation, that many of the intractable and dangerous forms of cuta- 
neous disease are of syphilitic origin, and he especially enumerates scrofula 
and its various manifestations, as also lupus, kelis, lepra, and psoriasis. We are 
not by any means prepared to admit such a sweeping conclusion as this ; nor 
do we see anything in the circumstances of the cases cited by the author as 
illustrating his views, which are calculated to elevate the latter above the cha- 
racter of loose and vague conjectures, such as men are too apt to invent, when 
speculating about subjects which have occupied much of their time and regard. 
Indeed, the author advances it as an hypothesis hereafter to be established, 
rather than as a settled fact. We suspect it must ever remain a mere matter 
of speculation. 

The treatment of syphilis receives its due share of attention in the concluding 
chapter. 



1852.] Wilson on Syphilis and Syphilitic Eruptions. 209 



First, as to the prophylaxis. Inasmuch as it is necessary to the occurrence 
of infection that the virus shall remain a certain length of time in contact with 
the mucous membrane or with the skin, the most obvious method of guarding 
against the absorption of the poison is to wash the parts carefully and tho- 
roughly. Mr. Wilson advises that the male should wash with soap and water, 
and that the female, in addition to the use of the same externally, should inject 
the vagina with weak vinegar and water, and subsequently bathe the external 
parts with a similar lotion. These operations should be performed with great 
care, to insure thorough removal of the virus from the numerous folds and fol- 
licular orifices. " Acids and alkalies possess the power of destroying the poison- 
ous qualities of the syphilitic poison but in order that these fluids shall exert 
their power, they must be brought in contact with every lurking atom of the 
virus, for so subtle and powerful is the latter that, according to Mr. Acton (Am. 
ed., p. 238), "one drop has been diluted with a pint of water, and the inocu- 
lated fluid has produced a pustule." If there be an excoriation upon the sur- 
face, it should be lightly touched with nitrate of silver, and covered with lint. 

The curative treatment divides itself into the local and the general. 

.If a patient present with a papule, a pustule, or a small ulcer, which has 
just appeared, this should immediately, and whether there be any doubt of its 
specific character or not, be touched with some caustic application, " with the 
double view of destroying the morbid structure of which it consists, and of set- 
ting up a new and healthy action, in place of the poison-generating one already 
in txistence or about to begin :" (p. 189.) In the choice of a caustic, says Mr. 
Wilson, " I have long given the preference to potassafusa; with it the destruc- 
tion of the tissues is effected totally, and the extent of destruction may be regu- 
lated with the utmost nicety. The potassa cum calce (Vienna paste) comes next 
in the list of preference ; then chloride of zinc, which is objectionable on account 
of the pain to which it gives rise ; then follow nitrate of silver, nitric acid, and 
the actual cautery, all of which I consider to be perfectly useless. If a patient 
were to tell me that his surgeon had cauterized the primary affection within an 
hour of its first appearance with the nitrate of silver, I should consider him as 
certain to have constitutional syphilis as if the sore had been left to itself," &c. 
After the cauterization, he advises the application of a piece of lint moistened 
with a solution of the watery extract of opium (gj cf ^iv), and over this the 
common tepid water dressing ; rest, and support of the organ, in the male, 
should be enjoined ; attention should be also paid to the condition of the skin 
and digestive organs. 

If the primary affection be not seen until a few days have elapsed, " consti- 
tutional treatment is most necessary and most important." The indications of 
treatment he considers to be: 1, " to prevent the increase of the poisonous fer- 
ment in the blood," and 2, " to cause the removal by the natural emunctories 
of the body of the noxious poison, as rapidly as it may be formed." To fulfil 
the latter indication, he regards " Mercury, of all the known remedies for 
syphilis, as that which has for the greatest length of time maintained its 
character and warranted the confidence of medical men ; and for the simple 
reason that mercury alone possesses the power of acting upon all the emunc- 
tories of the body ; it excites action in the bowels, the liver, the kidneys, the 
mucous membrane, and even in the skin ; mercury, then, deserves to be con- 
sidered the great antidote of syphilis." Of the different preparations of this 
drug, Mr. Wilson prefers the blue pill, where it can be procured perfectly pure, 
in from two to five grain doses, to be taken for the first five or six days at night 
only, and afterwards night and morning. He regards it, however, as inappli- 
cable to the treatment of the inflammatory and phagedenic sores; "these 
must be treated according to the common principles of surgical medicine." 

It is not necessary that we shall follow the author in his details of the treat- 
ment; we shall merely remark that in these he displays his usual caution and 
judgment in the enforcement of his particular views. 

In the treatment of the manifestations of the chronic forms of syphilis, the 
tertiary period of Ricord, mercury he considers to be decidedly injurious, and 
employs the iodide of potassium, cod liver oil, Donovan's solution, &c. 

In conclusion, we take pleasure in observing that, although we have not been 



210 



Bibliographical Notices. 



[July, 



able to agree with the distinguished author in some of the views which he has 
advocated in his book, we yet commend it to our readers as unfolding new 
views of syphilis in many of its aspects, and as containing many simple and 
satisfactory aids in its diagnosis and treatment. The text is illustrated by four 
exquisitely finished plates, which exhibit very well the characteristic appear- 
ances of many of the syphilides. Our readers are doubtless familiar with the 
illustrations accompanying Mr. Wilson's book on Diseases of the Skin, pub- 
lished some years ago; and it is only needful for us to say that the plates be- 
longing to the volume under notice are executed in the same artistic manner 
as were those. 

We understand that Messrs. Blanchard & Lea are preparing for the press a 
reprint of this book; and that it is their intention to spare no labour or expense 
to render the American as nearly as possible equal in excellence to the English 
edition. 

F. W. S. 



Art. XXIV. — TTber secondare Erkranknng einzelner R'dckensmarksstrdnge una* 
Hirer Fortsetzungen zum Gehirne. 

A Consideration of the Secondary Degeneration of Particular Fasciculi of the 
Spinal Cord, and their Continuation to the Brain. — Transactions of the Impe- 
rial Academy of Science, Vienna, Vol. VI. part 3, 1851. 

This is the title of a very curious and highly interesting memoir read before 
the Austrian Imperial Academy of Sciences, by Dr. Ludwig Turck, and printed 
in the third number of the sixth volume of their Transactions. (1851.) 

The author states that he has found a peculiar pathological alteration of the 
spinal cord subsequent to disease of the brain, which consists in a deposit of 
numerous granular cells upon the side of the spinal marrow opposite to that por- 
tion of the brain in which disease has originated ; and that he had communicated 
these observations to the " Society of Physicians of Vienna," in the year 1850. 

It since occurred to him that this fact might be constant in regard to par- 
ticular fasciculi of the spinal marrow, without involving the entire structure of 
the cord, in which there was an alteration of tissue. Induced by such conclu- 
sions, Dr. Turck commenced a series of careful examinations, by which he 
became convinced that particular fasciculi were always secondarily diseased, 
depending upon that point of the brain or spinal marrow which was the focus 
of morbid action ; such fasciculi only becoming altered as were in direct con- 
nection with these diseased points; and that thus information was attainable 
relative to the origin and office of such fasciculi. 

The manner of procedure was as follows : after the spinal nerves had been 
exactly counted to establish the precise portion to be examined, the cord was 
horizontally divided by a pair of sharp scissors, and the stump obtained in this 
way turned upwards, and its exact contour, as well as that of the gray matter, 
delineated with precision. Next, from a very small portion of the horizontal 
surface, a thin layer of medullary matter is removed by a pair of delicate scis- 
sors curved at the point; this portion of the surface selected for examination 
being marked on the magnified drawing, previously made, of the entire section. 
The fraction removed is then subjected to the most accurate microscopic scru- 
tiny, and the result written down under a letter of the alphabet, correspond- 
ing with a letter assumed to distinguish the same relative point on the previously 
delineated plan ; this was continued until the entire surface had been thoroughly 
examined. Dr. Turck contends that the formation of granular cells is not a 
propagation of the abnormal condition from the point of disease, but the con- 
sequence of the loss of function in fibres which no longer receive those impulses 
requisite to continue them in the discharge of their duties ; and as in other 
structures, the loss of function involves a degeneration of tissue, the fibres of 
nerves no longer conveying the currents of nervous excitation degenerate in 
obedience to a universal law. In evidence that these granular cells are not 



1852.] Turck ; Secondary Degeneration of Fasciculi of Spinal Cord. 211 



propagated from a diseased point, Dr. Turck has never observed them earlier 
than six months after the occurrence of disease in the nervous centres, and 
then not in a decreasing ratio from such a point ; but he has known the spinal 
marrow remain in apparently perfect health, while the walls of an effusion were 
thickly covered by these abnormal products, and upon their subsequent ap- 
pearance he has seen them select certain portions of the spinal cord, as for in- 
stance, just above the origin of the plexus of the lower extremities, to appear 
in much greater intensity than nearer the seat of disease. 

Paraplegia offers a good example of the course of this degeneration of struc- 
ture, the granular cells being found in such cases in large numbers at the seat 
of injury, from whence they diminish rapidly, till, within a short distance, they 
are entirely confined to the exact outline of individual fasciculi, in which they 
mount upwards as far as the pons Varolii. These were in no instance the same 
fasciculi in which a deposit was found secondary to disease of the brain; the 
latter fasciculi remaining in paraplegia entirely free, from the circumstance 
(deduced from these observations) that these fasciculi, having a different office 
to fulfil, only sympathized with disease at points from whence they derived 
their functional power. Upon the occurrence of effusion into the spinal column, 
for instance, a deposit of granular cells must, after a time, ensue, in conse- 
quence of the abrogation of function of the various fasciculi composing the 
cord, either above or below the point of disease regulated by the employment 
of these fasciculi ; those devoted to the conveyance of centripetal currents de- 
generating above the point of effusion, and those used for centrifugal purposes 
below. The fact of these fasciculi being centripetal or centrifugal, being de- 
rived by a posteriori reasoning from the observance of constant deposits within 
their walls. 

With reference to a very natural conclusion that these granular cells would 
be produced in an exuded fluid, observation teaches that the smaller capillary 
vessels of a part, those that would naturally take important action in the pro- 
duction of such a pabulum, are comparatively free from the presence of these 
abnormal products : while the larger vessels have granular cells congregated 
around their external walls, as a thread is converted to a similar purpose when 
suspended in a saline solution, and becomes a fixed point for crystalline deposit. 
Another argument against these results being the product of exudation, is the 
fact of the exact limits to which they are restricted in being confined exclusively 
to individual fasciculi ; and as Dr. Turck has never observed the slightest ves- 
tige of inflammation, it would seem that these abnormal cells were rather the 
consequence of anomalous nutrition, or a product of decomposition in struc- 
tures no longer required to discharge a previous function. Dr. Turck states 
that he has seen cases in which the distribution of cells exceeded the limits that 
a strict accordance with the above conclusions would have prescribed for their 
occurrence ; for such a condition he confesses himself at present unable to 
account. 

Now, instances of this kind are very far from being a defect ; for they disarm 
the opposition which novel representations are always apt to excite, of the 
weighty accusation that the entire explanation afforded is rather the result of 
preconceived theoretical direction of mind coercing observation, than an honest 
exposition of fact ; it being an inherent attribute of theorists to prescribe for all 
cases a solution, instead of waiting for truthful observation to offer amend- 
ments. 

The granular cells increase in size in proportion to the long continuance of 
disease, and are often a precursor of atrophy ; a result which Rokitansky men- 
tions as occurring in certain portions of the nervous system secondary to local 
affections, and on one occasion he witnessed the loss of an entire hemisphere. 

These cells are soluble in ether; and in a high grade of disease exhibit the 
presence of free globules of fat. 

The following is a translation of the resume which Dr. Turck has made 
of the deductions which he drew from his examinations; and embodies 
everything of value that could be condensed from details of observation and 
processes of reasoning, given at length in the original paper in the Transactions 
of the Imperial Academy. This resume' is now presented, accompanied with his 



212 



Bibliographical Notices. 



[July, 



method of procedure, to American observers, to receive that consideration 
wbich its merits may demand : and, free from the cliques and jealousies of rival 
European schools, it is for them to decide upon its worth — to engraft upon it 
the results of their own labour should the stock prove good, and to reject it if, 
upon a more thorough acquaintance, it should be found without value ; in either 
case, having first weighed the question with a steady hand in the scales of 
justice. 

1st. When, owing to protracted disease in the brain or spinal column, the 
nervous currents, through certain fasciculi, remain for a length of time inter- 
rupted, these fasciculi, in consequence of the abrogation of their office, have 
produced within them numbers of granular cells ; these represent the beginning 
of a more complete metamorphosis, to be perfected after a further lapse of time. 

2d. When in such cases, transverse sections are made through the spinal 
marrow, medulla oblongata, pons Varolii, and the brain and its ganglia, and 
those points which are shown by the presence of abnormal cells upon these 
sections to be diseased are compared with reference to their position, we are 
enabled to pursue the anatomical track of these secondarily diseased fasciculi, 
and to arrive at conclusions with regard to the course of nervous currents. The 
results which follow agree in part with the previous views of the direction of 
nerve-fibres, and are partly such as could not be reached by anatomy and phy- 
siology alone. 

3d. A fasciculus of the spinal marrow descends from the crus cerebri, continu- 
ing through the longitudinal fibres of the pons Varolii and pyramid of the same 
side, until, reaching the decussation of the latter in the medulla oblongata (in 
one case in two fasciculi), it passes over to the opposite side, and descends 
almost to the extreme end of the spinal cord, constituting the posterior half of 
its lateral column. This we designate the "pyramidal track of the lateral 
column." 

4th. The "pyramidal track of the lateral column" conveys a centrifugal cur- 
rent proceeding from the prominentias lentiformes, corpora striata, optic thala- 
mus, and medullary matter of the cerebrum (of which it cannot be said with 
certainty that it is a motor impulse), towards that side of the body opposite to 
the diseased half of the brain, but to the same side on which the fasciculus con- 
ducting this current is placed in the spinal column. This track is found to be 
diseased secondarily throughout, in cases of chronic apoplexy and other ence- 
phalic affections. 

5th. A second fasciculus proceeds from the crus cerebri, and through the pons 
Varolii of the same side, as longitudinal fibres ; but, instead of crossing in the 
medulla oblongata, as was the case with the preceding pyramidal track, this 
second fasciculus descends on the same side of the spinal cord as an internal 
division of the anterior column. Where, however, its secondary affections ter- 
minate rather higher than those of the posterior section of the opposite lateral 
column, this we call the " enveloping track of the anterior column." 

6th. The " enveloping track of the anterior column" conveys an impulse in a 
centrifugal direction to that side of the body opposite to the disease of the brain, 
and likewise opposite to the conducting track of the spinal marrow ; and brought 
from the prominentias lentiformes, and corpora striata. This track, probably, 
conveys a motor impulse, and it is found secondarily affected when disease exists 
in one or both of the last-mentioned ganglia of the brain. 

7th. With the exception of the above-mentioned tracks, neither the gray 
matter, nor any other of the fasciculi was found diseased secondarily to affection 
of the brain. 

8th. It is not decided whether the motor impulses, proceeding from the cere- 
brum, are conducted downwards through these two above-mentioned tracks 
alone, or seek some other way. 

9th. The internal section of the posterior column continues through the soft 
fasciculi of the crura, and appears to reach its final termination on the floor of 
the fourth ventricle. By this track a centripetal nervous current is conducted, 
and it is found secondarily diseased above that point in the spinal cord at which 
effusion has destroyed the conducting power and arrested the centripetal 
stream. 



1852.] 



Graham's Elements of Chemistry. 



213 



10th. A second likewise centripetal tendency is found in the posterior half 
of the lateral column, and consequently a deposition of granular cells within 
this track above a point at which an affection of the spinal cord may have 
occurred. In this posterior half there is both a centripetal and centrifugal con- 
duction. The fasciculi united in the posterior half of the lateral column sepa- 
rate in the medulla oblongata, the centrifugal coming from the pyramids, 
whilst the centripetal in the medulla directing itself always more backwards 
mounts to the corpora restiformia. 

11th. With the exception of the centripetal tracks mentioned in number 9 and 
10, neither the gray matter nor any other fasciculi of the spinal cord were found 
secondarily diseased. 

12th. Whether through these two tracks the sense of muscular tonicity or 
ordinary sensation is manifested remains at the present unascertained. 

13th. The remaining fasciculi of the spinal cord are to be considered as sepa- 
rated in their anatomical and physiological character from those that have been 
treated of above. In the first place, the separation in the cervical portion of the 
spinal marrow exhibited between the external and internal sections of the ante- 
rior column by the sulcus intermed. anterior, is established as a complete divi- 
sion of those parts extending to the lowest extremity of the spinal cord. The 
same is probable with regard to the separation of the posterior column into two 
lateral sections by the sulcus intermed. posterior, although this is only demon- 
strated so far as the fourth thoracic pair of nerves. A similar division is found 
between the anterior and posterior sections of the lateral column, not exhibited, 
however, by any external mark of separation. Each half, therefore, of the spinal 
cord includes six fasciculi. Secondly, it is evident that these fasciculi do not 
conduct a centripetal current originating in either the lower extremities or the 
lower section of the trunk ; perhaps they may serve for such currents from the 
upper extremities, or the superior portions of the trunk, but this is not proba- 
ble. And it is yet undecided whether these tracks are used by centrifugal 
stimulation having its origin in special portions of the greater or lesser brain. 

14th! The gray matter is not subject to the formation within it of these abnor- 
mal cells ; from which, however, no conclusion can be absolutely drawn with 
regard to its powers of conduction. C. W. 



Art. XXY. — Elements of Chemistry ; including tlie Applications of the Science in 
the Arts. — By Thomas Graham, F. K. S., Professor of Chemistry in University 
College, London ; Vice-President of the Chemical Society, &c. &c. Second 
American from an entirely revised and greatly enlarged English edition, with 
numerous wood engravings. Edited, with notes, by Robert Bridges, M. D., 
Professor of Chemistry in the Philadelphia College of Pharmacy, &c. Phila- 
delphia, Blanchard & Lea, 1852: 8vo. 

The sciences are now engaging the attention of mankind to such an ex- 
tent as to draw to their investigation the ablest minds, and from this has re- 
sulted their rapid advancement, the discovery of new facts, the correction 
of old views, and the formation of more just conceptions of their pheno- 
mena. In the science of chemistry this is particularly the case, and this 
involves the necessity, in every successive edition of any work on this sub- 
ject, of a strict revision and adaptation to the advances made, and the 
incorporation of recent discoveries, when in conformity with the objects of 
the publication. The present edition of Graham's Chemistry evinces that 
the author has been fully impressed with the above views, as will be evident 
to any who will compare it with the first. Although only comprising one-half of 
the work, the matter added has enlarged its extent about sixty pages, including 
numerous additional illustrations by cuts. The alterations in the original text 
Consist of occasional corrections, numerical and others, interpolation of addi- 
tional observations, varying in extent from short sentences to whole pages, and 



214 



Bibliographical Notices. 



[July, 



in re-writing parts or the whole of some subjects, so as to convey an accurate 
knowledge of the present information on these points. In some instances the 
arrangement has undergone alteration, and with advantage in approximating 
kindred subjects which were before too distant. These differences from the 
first edition are too numerous for any detail, very frequently being apparent in 
each of several successive pages, and very seldom exhibiting any long interval. 
The merits of this work are so well known that comment is unnecessary, and 
the present edition is calculated to sustain, and indeed elevate, the reputation 
the author has already acquired. 

In the typographical execution there is an evident improvement over the 
first American edition, and there will also be noticed a modification in the 
arrangement, in the almost total absence of foot notes, the additions of the edi- 
tor being inclosed in brackets, and with the bibliographical references incor- 
porated in the original text of the work. In regard to these latter, it will be 
noticed that their number, which in the first edition was very great, has been 
still further increased, not in the newly-added matter only, but also in the 
older parts — a very valuable aid for those who desire to investigate any sub- 
ject in all its details. 



Art. XXVI. — Review of Materia Medica,for the Use of Students. By John B. 
Biddle, M. D. etc. etc. With illustrations. Philadelphia, Lindsay & Blak- 
iston, 1852: 12mo. pp. 322. 

This work belongs to a class of productions which, when kept within their 
proper sphere, are unquestionably calculated to facilitate the labours of the 
student in the particular branches of knowledge of which they treat, but which, 
when adopted as substitutes for more extended and elaborate treatises, are pro- 
ductive of no little mischief. As condensed reviews of the elements of the 
science to which they refer — embracing a brief summary of its leading facts 
and principles — they may serve as useful guides to a course of lectures, while 
at the same time they will aid the student in his mental review of the know- 
ledge to the acquisition of which his time and attention have been devoted; cor- 
recting misapprehensions, indicating to him what may have escaped his notice, 
and recalling such points as had been but slightly impressed upon his mind, 
and, in consequence, liable to be quickly forgotten. When, however, as is too 
often the case, they are made the sole guides to science — when the student 
believes that, by committing the brief summary they present of leading facts and 
principles to memory, he has acquired an adequate acquaintance with any 
given branch of science — their tendency is then in the highest degree mischiev- 
ous. They discourage close and prolonged application — that full and thorough 
acquisition of knowledge which can alone render it permanent and profitable ; 
and, by substituting in the student a mere act of memory for the exercise of 
the reasoning, the judging, and the comparing faculties of the mind, works of 
the character referred to are liable to impede even the subsequent progress of 
those who have been so unfortunate as to make them their sole guides, render- 
ing to such the most favourable opportunities subsequently presented for im- 
provement in any department of science, barren and profitless. 

Keeping in mind then that the work before us is to be viewed as a mere ele- 
mentary treatise on the Materia Medica, as an outline only of the leading facts 
and principles usually comprised in this branch of medicine, as set forth by the 
standard authorities ; as a review of, rather than as an exposition of the science 
of which it treats, we can freely recommend it to the attention of the American 
student. 

It is, in fact, a judiciously executed manual of materia medica, indicating a 
perfect familiarity with the subject on the part of its author, and an admirable 
facility in condensation: all that is actually important in relation to the several 
received pharmacological remedies being concisely indicated, but at the same 
time with the utmost clearness and precision. 

D. F. C. 



1852.] 



215 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On the Molecular Origin of the Tissues. By Dr. Bennett. — The great 
generalization of Schwann was that ail tissues are derived from cells. Subse- 
quently, it was ascertained that the nucleus, or cell-germ, exercised an influence 
on the tissues, independent of its cell-wall ; and it was endeavoured to be shown, 
that some tissues might be derived directly from nuclei. The object of this 
communication was to point out that the nuclei themselves originated from 
smaller bodies, viz., molecules ; that these were the origin of every texture, and 
to indicate some of the laws which governed their formation, arrangement, and 
subsequent development. From a review of the observations of Schleiden, 
Schwann, and Martin Barry, the author pointed out how the first appearance, 
observable in all developing organisms, was a mass of molecules and granules, 
which, by aggregating or melting together, constituted the cell-germ. Around 
the cell-germ other molecules were formed, which again, by melting together, 
constituted the cell-wall. Further development, in like manner, proceeded by 
the apposition of molecules. At any period in the process of evolution, the 
onward progress might be checked when the structure became disintegrated in 
the inverse manner to its formation : First, the cell-wall became dissolved, then 
the nucleus, both of which were reduced, first to molecules, then to a fluid. 
Hence there were molecules of evolution and molecules of disintegration. Oc- 
casionally, between the cell-wall and nucleus, secondary molecules were formed, 
which constituted peculiar secretions, as they have been termed : these might 
be called molecules of transformation. The author described the origin and 
mode of formation of these three kinds of molecules, their physiological and 
pathological importance, and pointed out the advance which had been made in 
our knowledge of molecular formation by the observations of Ascherson Hart- 
ing, and Melsen. In complex organisms, the higher tissues were formed by 
an elaboration of blastema, mainly due to the successive evolution, transforma- 
tion, and disintegration of matter, by means of the three different kinds of 
molecules, of which the author gave numerous examples, derived from the 
elaboration of the ovum, of the blood, the transformation of insects, the process 
of fissiparous division in the lower animal forms, &c. He pointed out that 
molecules had independent movements, sometimes physical, as in the case of 
Brown's molecular movements, at other times vital, as seen in many organisms. 
That occasionally we had molecular fibres, from the aggregation end to end of 
molecules, in the same way as we have nuclear cell-fibres. Moreover, each 
kind of fibre could assume inherent contractility, as in the case of vibriones, 
which might be called contractile molecular fibres, as spermatozoa might be 
denominated contractile nuclear, and cilia contractile cell-fibres. The author 
concluded a lengthy communication by remarking, that not only did a study of 
the molecular element indicate the origin and development of healthy and 
morbid product, but it pointed out the basis on which a rational treatment was 



216 



Progress of the Medical Sciences. 



[July, 



to be founded, as far as diseases of nutrition were concerned. Thus in tuber- 
cular diseases, where molecules of evolution were deficient from absence of the 
fatty element in the chyle, animal oils were indicated to favour the production 
of such molecules. When the blood was diseased, in cases of gout, rheumatism, 
rachitis, scurvy, &c, such morbid conditions could only be removed by the in- 
troduction of substances which either directly or indirectly, physically or 
chemically, favoured the production of certain molecules of transformation, as 
those in the blood ; and when any of the tissues seem redundant and hyper- 
trophied, tumours constituted the morbid condition ; thus the cure would depend 
on the discovery of those means, whereby granules of disintegration might be 
induced and subsequently eliminated. — Proceedings of Edinburgh Physiological 
Society, in Monthly Journal of Medical Science. 

2. Pathological Cell-Development. — Dr. Gairdner made a verbal communi- 
cation of considerable length, on certain peculiarities of pathological and other 
structures, as bearing on the different theories of cell-development. He con- 
sidered the cell-theory of Schleiden and Schwann, although it led to the dis- 
covery of many interesting facts, and really important morphological generali- 
zations, to have been utterly overthrown, as a general theory of development, 
by the progress of scientific inquiry. The "cell" of these physiologists, so far 
from having the fixed and uniform character of a basic type of form, was the 
most fluctuating and uncertain of all morphological creations. Its form, size, 
law of development, were either confessedly uncertain, or had to be stated in 
terms so vague as to lead to the conclusion that form and substance, and, per- 
haps, microscopic size, were the only attributes essential to the idea of a cell. 
No one could tell, in practice, what was a cell-wall and what was a nucleus, 
and no one could give a satisfactory theoretical definition of either, or resolve, 
for all cases, which of the two preceded the other in the course of development. 
The theory of " germinal centres/' held by Mr. Goodsir, in so far as it ascribed 
to certain " nucleated particles" the function of the cell, was, in Dr. Gairdner' s 
opinion, subject, in like manner, to the imputation either of vagueness or of want 
of comprehensiveness. If these nucleated particles came under any more precise 
definition than was applicable to every kind of organic or inorganic structural 
atom, it would be very difficult to show that they monopolized and centralized 
the whole functional activity of the organism, or were more necessary than 
other parts to its growth and preservation. He (Dr. Gairdner) believed that 
there was no distinction in the organism of passive and active atoms, and con- 
sidered every point and every molecule as endowed with its own life, and placed, 
in its own peculiar sphere of activity, in harmony with the rest. He agreed 
with Dr. Bennett in thinking, that many tissues arose from elements far more 
minute than any to which the term cell or nucleus had been applied; indeed, 
he was far from thinking that our microscopes had conducted us back to the 
real germs of the tissues, and considered that the structural, like the chemical 
atom, still lay in the remote region of hypothesis. He firmly believed, how- 
ever, in these hypothetical germs, and could not conceive of the tissues being 
formed by anything like what the Epicureans would have called a concourse of 
atoms, according to their physical and chemical properties. Hence he did not 
think, that by the mere introduction of peculiar molecular elements into the 
food, we could either create new tissues or destroy old ones, so directly and 
simply as had been hinted by Dr. Bennett. The positive part of Dr. Gairdner's 
communication consisted in the detail of observations on the structure and de- 
velopment of the pus-corpuscles and other pathological structures, intended to 
show that the so-called cell-walls were often generated in great numbers with- 
out nuclei; and that the whole of the facts of cell-development contradicted the 
idea of any part of a cell being, more than another, the source of its functional 
activity and development. In regard to the development of fibres, Dr. Gairdner 
thought there was no evidence that these were ever produced from cells, under 
any circumstances ; and he had long been in the habit of regarding the so-called 
fibre-cells as merely transition types in morphology, and not parts of a physio- 
logical succession of stages of development. It was difficult to prove this view 
any more than its opposite, but he thought any one who would give it con- 



1852.] 



Anatomy and Physiology. 



217 



sideration in original observations would find it in harmony with all the known 
facts, both physiological and pathological. 

Dr. Sanders remarked that Kolliker had demonstrated unstriped muscular 
texture to be composed of permanent fibre-cells, Avhose development by elonga- 
tion of spherical nucleated cellules he had traced in the pregnant uterus. This 
texture, therefore, had been lately found a corroboration of Schwann's views, 
which it was previously thought to contradict. Doubtless some textures were 
formed without passing through the form of cells ; thus, particularly, fibrous 
tissue, as observed in cartilage by Redfern and Donders ; yet the constant pre- 
sence of nuclei and cellules in skin, mucous membranes, glands, and bone ; 
their transition forms ; their extensive development in the foetus ; their occur- 
rence in newly-forming textures in all organized beings, animal and vegetable, 
gave immense weight to Schleiden and Schwann's views, and justified our ad- 
herence to them in physiological anatomy. In pathology, their application 
appeared more limited, and less satisfactory. Dr. Gairdner's statements, and 
a gaining distrust among observers at home and abroad, proved the necessity 
of submitting the " cell theory" to the criticism of new and extended observa- 
tions; it ought not, however, to be rejected, but only thoroughly reinvestigated. 
—Ibid. 

3. Structure of Arteries. — Mr. Drummond exhibited several preparations of 
the middle coat of the aorta in the ox, for the purpose of showing, first, that 
many of the fibres present a distinctly transverse striated appearance. They 
are branched generally, and anastomose with neighbouring fibres, presenting an 
appearance very similar to the branching striated muscular fibre, seen in some 
of the insecta. From muscular fibre, however, they differ in their chemical 
constitution, agreeing in this respect with yellow elastic tissue. They are in 
all probability analogous to the striated fibres occurring in the ligamentum 
nuchae of some animals. When viewed with a high power, many of them seem 
to present a series of cup-shaped depressions, arranged in linear series in the 
longitudinal axis of the fibre, with intervening ridges or partitions, to which 
the striated appearance is owing. Second, that the structure described under 
the name of the fenestrated coat of Henle, as it occurs in the middle coat of the 
aorta in the ox, is formed by the amalgamation of the network of the yellow 
elastic fibres, the fenestras or perforations being merely the remains of the 
areolas between the fibres. The fibres which go to the formation of this coat 
often present traces of the transverse striated appearance above described. 
Preparations were also shown illustrating the development of the yellow elastic 
tissues as it takes place in the ligamentum nuchas of the calf. A description 
of the development of this tissue will be given in a future report. — Ibid. 

4. Development of Pus- Corpuscles. — Dr. Sanders reported to the Physiologi- 
cal Society of Edinburgh some observations on the corpuscular contents of the 
vesicles of smallpox. On the fourth day of the eruption, the fluid of the vesicle 
presented some clear, gray nuclei, about the size of blood-corpuscles, and show- 
ing only one or two granules in their interior when acted on by acetic acid. On 
the fifth and sixth days, these corpuscles had increased in size and numbers, and 
become more granular ; the amount of free molecules and granules, at first very 
scanty, was now greater. On the sixth and seventh days, nucleated cells, spheri- 
cal, and more or less granular, occurred along with the corpuscles before de- 
scribed ; and a few large cells, of the diameter of four to five blood-disks, and con- 
taining several nuclei imbedded in granular matter, were also observed. The 
corpuscles, however, were the chief elements ; they were granular, like the usual 
pus-corpuscles, and presented under the action of acetic acid, some a triple nu- 
cleus, others several granules. From this stage, when the fluid was distinctly 
purulent in its characters, even to the naked eye, up to the time of scabbing, or 
twelfth day of the eruption, the changes were a gradual increase in the free 
granular matter, and a diminution in the amount of corpuscles, which at last 
gave place to the granular matter ; which last, along with epithelium-cells, dried 
up to form the scab. The fluid of the vesicles, therefore, exhibits a process of 



218 



Progress of the Medical Sciences. 



[July, 



cell-growth from nuclei to pus-corpuscles, and nucleated cells, which become 
more and more granular, and break up at last into free granular matter. The 
so-called pus-corpuscles are a stage in cell-formation. Considering the small 
amount of granular matter, both free and within the corpuscles at the beginning, 
and its great abundance subsequently, the author was disposed to doubt the for- 
mation of these corpuscles and cells by the aggregation of granules subsequently 
surrounded by a cell-wall, but regarded the granular matter rather as a produc- 
tion of cell-growth. — Ibid. 

5. Fibrin in the Blood of the Fortus. — Dr. Drumhond mentioned to the Phy- 
siological Society of Edinburgh that he had recently found the blood of the 
foetus to contain a considerable quantity of fibrin. Zimmerman asserts it con- 
tains none. 

6. Influence of Muscular Paralysis on the Modification of the Blood, and on 
the Duration of Irritability. — M. Browx-Sequard, a distinguished Parisian 
experimental physiologist, at present in this country, states that after the sec- 
tion of the nerves of a limb, the transformation of arterial blood into venous is 
imperfectly effected ; but that the change is perfect if the paralyzed limb be 
galvanized. 

The same experimenter has shown that, when the muscles of one limb have 
been paralyzed by section of their nerves a few days previously, their irrita- 
bility lasts much longer after death than that of the muscles of the other limb ; 
and their cadaveric rigidity is much later in coming on. — Gazette MM. de Paris, 
Feb. 1, March 6. 

7. Mode of Termination of the Nerves in the Skin of the Fingers. — Dr. Ru- 
dolph Wagner has communicated to the Royal Society of Gottingen the fol- 
lowing results of his investigations relative to the distribution of the nerves in 
the skin of the tactile extremities of the fingers : — 

What are usually called the tactile papillae are of two kinds, namely, vascular 
papillae, which only contain capillary loops ; and nervous papillae, which are 
placed between them. These last have a conical form ; and each of them con- 
tains in its interior a peculiar corpuscle, also of conical form, which receives 
the finest of the nervous fibrils that enter the papilla. Each primitive nerve- 
fibre divides into a great number of smaller branches, to which these tactile 
corpuscles are attached ; and thus each is connected with several corpuscles. 
It is further considered by Wagner that each single fibre conducts the impres- 
sions made upon any of these branches to a certain spot in the nervous centres ; 
and that thus but a single sensory impression is produced, whether the cor- 
puscles supplied by any one fibre are touched separately, or all together. — 
Gaz. Medicate, March 6, 1852. 

8. On the Function of the Spleen and other Lymphatic Glands as Secretors of 
Blood. — The Monthly Journal of Medical Science, for March, 1852, contains a 
very interesting paper on this subject, by Prof. J. H. Bexxett, M. D. From 
the various facts therein stated he considers himself justified in drawing the 
following conclusions : — 

1. That the blood-corpuscles of vertebrate animals are originally formed in 
the lymphatic glandular system, and that the great majority of them, on joining 
the circulation, become coloured in a manner that is as yet unexplained. Hence 
the blood may be considered as a secretion from the lymphatic glands, although 
in the higher animals that secretion only becomes fully formed after it has re- 
ceived colour by exposure to oxygen in the lungs. 

2. That, in mammalia, the lymphatic glandular system is composed of the 
spleen, thymus, thyroid, supra-renal, pituitary, pineal, and lymphatic glands. 

3. That, in fishes, reptiles, and birds, the coloured blood-corpuscles are 
nucleated cells, originating in these glands ; but that, in mammals, they are 
free nuclei, sometimes derived as such from the glands ; at others, developed 
within colourless cells. 



1852.] 



Organic Chemistry. 



219 



4. That, in certain hypertrophies of the lymphatic glands, their cell elements 
are multiplied to an unusual extent, and under such circumstances find their 
way into the blood, and constitute an increase in the number of its colourless 
cells. This is leucocythgemia. 

5. That the solution of the blood-corpuscles, conjoined with the effete matter 
derived from the secondary digestion of the tissues, which is not converted into 
albumen, constitutes blood-fibrin. 

9. Influence of Medicines on the Temperature of the Body. — MM. Dumaril, 
Demarqtjay, and Lecomte have associated themselves together for the purpose 
of inquiring into the effect of medicines on- temperature. Their experiments 
were made on dogs. To state the results briefly, they found that cantharides, 
in doses of from one to six grains, raised the temperature in six hours nearly 
4° Fahr. ; canella, in a dose of from eight to ten drachms, elevated the tem- 
perature 3° Fahr. ; and a second dose raised 2° more. One drachm of secale 
cornutum in five hours increased the temperature about 1£° Fahr. in five hours. 
Acetate of ammonia injected into the veins augmented also the temperature ; put 
into the stomach, it produced the same effect in a less degree. Phosphorus, in 
doses of a grain and a-half to three grains, lowered the temperature. Strych- 
nine produced no effect. 

Certain purgatives were tried, such as colocynth, castor oil, etc., the effects 
varied according to the dose ; usually it was lowered, and then elevated to about 
1£° Fahr. above the standard. 

Emetics — as ipecacuanha, sulphate of copper — produced in small doses a 
little elevation ; but, in large doses, lowering of temperature to the extent of 2° 
or 3° Fahr. — Med. Times and Gazette, May 22, 1852, from L' Union Me'dicale. 



ORGANIC CHEMISTRY. 

10. Constituents of the Splenic Fluid. — In the fluid obtained by boiling a 
spleen in water, Scherer has discovered that, besides some of the constituents 
of the juice of flesh, some nitrogenous principles are present, viz., uric acid and 
a body hitherto unknown, for which he proposes the name hypoxanthin. The 
formula for the latter is C 5 !! 2 ^^). Hypoxanthin is a powdery crystalline mass, 
soluble in 1090 parts of cold, and in 180 parts of warm, water; heated with 
nitric acid, it forms a yellow stain, which liquor potassa, in the cold, turns red, 
and, with heat, changes to a lively purple, like murexid. The composition of 
hypoxanthin is of great interest, as may be seen by placing together its for- 
mula, and the formula of zanthin, as determined by Liebig and Wohler, and of 
uric acid: — 

Hypoxanthin C 5 H 2 N 2 

Zanthin C 5 H 2 N 2 2 

Uric acid C 5 H 2 N 2 3 

Hypoxanthin has been found, not only in the spleen of men and oxen, but in 
the fluid pressed from the muscular substance of the heart. Also, very lately, 
Gerhard, a pupil of Scherer's, has detected it in small quantities in the blood 
of oxen. 

In addition to uric acid and hypoxanthin, Scherer has found in this splenic 
fluid other bodies, viz. : — 

1. A new nitrogenous crystallizable body, which resembles, excepting in 
containing no sulphur, the bile principle, he terms it lienen. 

2. An albuminous substance, in combination with much iron. 

3. Iron in combination with acetic and lactic acids. 

4. A carbonaceous pigment, analogous to the colouring matters of urine and 
muscle. — Med. Times and Gazette, May 22, 1852, from Constat? s Jahresbericht. 



220 



Progress of the Medical Sciences. 



11. Composition of the Succus Entericus. — The composition of the intestinal 
fluid has lately been made the subject of an inaugural dissertation by Zander, a 
pupil of Bidder and Schmidt. An abstract of it is given by Scherer. The fluid 
•was obtained by tying the ductus communis choledochus and the pancreatic 
duct, and then making an intestinal fistula ; it was semi-fluid, stringy, colourless, 
always alkaline, though not always equally so. It contained, in 1000 parts, 
from*30 to 38 parts of solids, of which from 15 to 25 were soluble in alcohol, 
and from 5 to 13 were insoluble. It contained no albumen. It was found to 
possess the properties of dissolving flesh and coagulated albumen, and of 
changing starch into sugar. The pancreatic fluid and the bile did not appear 
to heighten the power it possessed of dissolving albumen. — Ibid., from Can- 
statt's Jahresbericht, 1852, Erster Band, p. 100. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

12. Treatment of Albuminuria. — Dr. C. Handfield Jones, in an interesting 
paper, read before the Medical Society of London, on the morbid conditions of 
the kidney giving rise to albuminous urine, presents the following interesting 
remarks relative to the treatment of those conditions: — 

The treatment of acute anasarca, whether occurring after exposure to cold 
and wet, after measles, or any other exciting cause, is sufficiently clear. The 
engorgement of the kidneys must be relieved : 1, by general blood-letting, if 
the patient's strength allow of it ; 2, by cupping on the loins, which should 
never be omitted in any case, as it powerfully counteracts the local determina- 
tion to the kidneys ; 3, by tartar emetic, which, acting very much, as it does, 
in pneumonia, depresses the action of the heart, unloads the congested renal 
capillaries, promotes the action of the skin, and acts beneficially in diminishing 
the tendency to secondary inflammations. The employment of tartar emetic 
should be continued some time, the patient being of course kept in bed : warm 
or hot air-baths should be occasionally employed, and this system persevered 
in until the urine is perfectly free from its dark sediment, gives no trace of 
albumen, and is passed in proper quantity. Many warnings have been given 
against the employment of saline diuretics in this complaint : I believe them to 
be as prejudicial while engorgement exists, as squills or the turpentines would 
be during the acute stage of a bronchitis or pneumonia ; but in the later stages 
of the complaint, I am inclined to think in moderate doses they are beneficial. 
I have recently had a case under my care, in which, after the acute symptoms 
had been subdued by the treatment above mentioned, I gave several doses of 
nitre with a little nitric acid and a bitter. The urine became quite free from 
deposit, and almost so from albumen. I afterwards changed this plan for a 
chalybeate, giving the man small doses of the carbonate of iron, on account of 
his anaemic aspect ; but I had soon to give this up, as it brought back again the 
turbid state of the urine, and had evidently induced fresh renal congestion. 
Again I returned to the nitre and acid, and the urine recovered its healthy con- 
dition, and continued so. The bowels should be kept open, but I should not 
recommend active purgation in this form of dropsical disease. 

"In the true Bright' s disease, it is of much importance to entertain correct 
ideas of the pathology ; and I do not indeed think it altogether indifferent 
whether we call the disease a subacute inflammation or a degeneration. For 
if it be an inflammation at all, bloodletting naturally suggests itself as one of 
the primary remedies, and the inexperienced might readily commit the error of 
employing it when useless and injurious. But if we name the disease a dege- 
neration, the mind at once turns to a more appropriate class of remedies. With 
respect to the secondary affections which renal degeneration induces, I can offer 
no new recommendations to the experienced Fellows of this Society, and these 
matters have been amply treated of by others. But whether anything may be 



1852.] 



Medical Pathology and Therapeutics. 



221 



done towards restoring the degenerated organ, and improving the quality of the 
deteriorated blood, is a subject scarce touched upon by any one, and yet of the 
highest interest. I can but offer a few suggestions. Of course when a kidney 
has utterly lost the greatest part of its cortical secreting structure, the lost tissue 
cannot be restored ; we cannot create the organ anew. But we can never during 
life know for certain whether an organ is so wasted, or whether it is only in 
process of being so ; we cannot tell whether it be not still possible to revive the 
decaying power, and to repair the injured mechanism. Our guiding ideas are, 
I think, two ; one recognizing the degenerative nature of the disease, its essen- 
tially low character, and therefore seeking to oppose it by all possible corrobo- 
rative means, and such as increase the general vigour of the system. Cod-liver 
oil, iron, quinine, regulated and active exercise, a system of training, such as 
an athletic employs, mental occupation; these, judiciously employed in the ear- 
liest stages, would, I believe, have much efficacy in counteracting the degenera- 
tive tendency. There is no doubt that the phthisical tendency, nay, the depo- 
sition of tubercle, in the lungs, may be checked, and life greatly prolonged, by 
such measures ; why should we not employ them, also, with effect in this kindred 
degeneration ? One can hardly help feeling that our duty, as practitioners, is 
not confined to the treatment of disease as it arises and excites alarm, but where 
the known diathesis, the exterior tokens of the inward infirmity, inspire us with 
too good ground for future apprehensions, we should give timely warning, and 
show how far easier it may be to avert the coming of the evil while yet distant, 
than to arrest it when its course has once begun. The second idea which would 
guide my treatment is the following, and is founded very much on the peculiar 
condition of the epithelium of the renal tubule in the earlier stages of degene- 
ration. We know that the alkalies and several of their salts exert a remarkable 
influence upon albumen and allied matters, dissolving them or tending to render 
them more fluid. Now it seems to me quite conceivable that alkalies, either 
pure, or preferably, perhaps, as vegetable salts, which become decomposed ere 
arriving at the kidneys, may so act on the bulky, coarse, heaped-up epithelium, 
as to cause it to assume a more fluid state, creating less obstruction, and more 
ready to undergo its appropriate changes. Such an effect, or at least a similar 
one, was certainly produced by Mr. Brandish in his treatment of scrofulous 
glands by liquor potassse ; and I cannot but think we may derive a useful hint 
from the practice he so successfully pursued. Of course, during the trial of such 
a plan, care must be taken to uphold the strength adequately, and not to push 
the remedy too fast. If this be not carefully observed, if the action of the remedy 
be not most carefully proportioned to the morbid process and to the general 
strength, it will cease to be a remedy ; it will only act injuriously. I regret 
that I have not experience, to lay before the Society, of the result of such a plan 
of proceeding as I have traced. I have only employed it partially in one case ; 
in this, indeed, all seemed to go on well for some time; the man, a gardener, 
who had Bright's disease in a marked form, kept to his employment, lost his 
dropsy, and seemed on the whole decidedly improved ; but after some weeks 
the lungs became gorged and vomiting set in, which I was unable to restrain. 
Probably the renal degeneration was too far advanced, and the attendant cir- 
cumstances were unfavourable ; but still the results were sufficiently encourag- 
ing to induce me certainly to try the plan again when a suitable opportunity 
may occur. Cupping on the loins even Frerichs does not counsel in Bright's 
disease, a measure which, if the disease depended essentially upon exudation 
into the kidney, would seem certainly advisable, at least in small quantities, or 
frequently repeated dry cupping, it should only be employed when there 
appears to be an attack of engorgement supervening on the degeneration, and 
then as sparingly as possible." — Lond. Journ. of Med., May, 1852. 

13. Treatment of Intermittent Fever by Quinine in large doses. By Dr. Meter, 
of Berlin. — Dr. Pfeuffer, in Henle and Pfeuffer's Zeitschrift, has contributed a 
paper having for its object to show that simple intermittent fever may be cured 
by a single large dose (ten grains) of quinine, administered on the day that the 
paroxysm is absent ; and that this dose is not followed by any evil effects. With 
this view, Dr. Pfeuffer adduces thirty-four cases of quotidian and tertian inter- 
No. XLVIL— July, 1852. 15 



222 



Progress of the Medical Sciences. 



mittent, treated between the 4th of May and 7th of August, which cases varied 
in their duration from four days to three months. In these, no return of the 
fever had been observed after the administration of the ten-grain doses of qui- 
nine ; whereas, although ague is not endemic or peculiarly obstinate in Heidel- 
berg, from forty to a hundred and twenty grains have usually been required in 
the ordinary treatment of cases of intermittent fever. Dr. Pfeuffer at the same 
time gives his patients a diet of soup, fish, flesh, vegetables, and wine. 

These observations, Dr. Meyer remarks, correspond with the statements of 
Torti, in 1709 ; and of Piorry and Bretonneau, in 1845 ; and Bittner, in 1850 ; 
also with the results of his own experience in six cases in which he had adopted 
the same treatment. Furthermore, from the end of November 1850, to the 1st 
of January 1851, twenty-eight soldiers suffering from intermittent fever were 
treated with quinine in ten-grain doses, given from five to ten hours before the 
paroxysm; in these cases the fit was arrested: a nutritious diet of meat and 
beer was supplied. Of these twenty-eight cases, none were quotidian, three 
were tertian, and twenty-five were quartan agues. The duration of the disease 
had varied from a fortnight to eighteen months. The patients had most of them 
previously taken quinine or arsenic without benefit. Eight of these patients 
had resided in the fortifications at Posen, which are situated at a high elevation, 
but deficient in light and air ; they had the quartan form of the disease, and 
had received no benefit in the military hospital ; in all, without exception, the 
spleen and liver were enlarged ; these individuals exhibiting an anaemic cachec- 
tic aspect, with sallow complexion, and oedema of the face and ankles. The 
prognosis in these cases was most unfavourable ; but the attack was suppressed 
by the ten-grain doses of quinine for eight, fourteen, twenty-one, and twenty- 
eight days, until at last the health was perfectly restored by the subsequent 
employment of ammoniated tincture of iron, a liberal diet, and fresh air. 

Of the remaining twenty cases, three were tertians, which severally had ex- 
isted fourteen days, three weeks, and three months ; thirteen were quartans, of 
which two had lasted two months ; four, three months ; one, twelve months ; 
one eighteen months ; these were cured by a single dose of ten grains of qui- 
nine : one quartan of three weeks' duration, and one of four months' standing, 
were cured by a second dose. Two cases remained rebellious ; one, that of a 
pale feeble individual, with splenic disease ; the other, a robust man, with only 
moderate enlargement of the spleen. Among the sixteen who were cured by 
the first dose of ten grains, two were remarkable ; one was a strong, healthy- 
looking man, who had had the disease eighteen months, with slight enlargement 
of the spleen ; the usual effects followed the administration of the large dose 
of quinine, and so far were evidence of perfect cure ; at the same time that 
painful dragging of the limbs, from which he had suffered during the entire 
progress of the disease, suddenly disappeared ; and the other, a patient in a lax 
anaemic condition, which had existed for twelve months, with an enlarged liver, 
and a spleen more than seven inches broad. It was for the treatment of the 
latter disease that the patient had been consigned to the hospital. A full dose 
of quinine, with liberal diet, had suppressed the fever during the time that he 
remained in hospital, and had effected a diminution of the spleen. The cure 
was permanently effected by a full diet and the internal use of iron. 

Dr. Meyer concludes, as the result of his observations, that Dr. Pfeuffer' s 
plan of giving a single large dose of quinine, although not uniformly successful, 
is successful in the majority of cases of uncomplicated quartan ague where no 
special endemic influence or altered condition of the blood interferes. The 
subsequent employment of iron as a medicine, and a nutritious full diet, secure 
the continuance of the benefit. The statement of Dr. Pfeuffer, that no ill effects 
follow the use of a large dose of quinine, is also confirmed by Dr. Meyer. — ■ 
Lond. Med. Gaz., Dec. 1851, from Casper's Wochenschrift. 

14. Iodine Clysters in the Treatment of Dysentery. — Dr. Eiiter believes that 
the great point to which practitioners have to direct their attention, is the 
enormous amount of organic losses consequent on the continuance of this affec- 
tion; so that, according to (Esterlen,* within three weeks, more than the entire 



* See British and Foreign Medico-Chirurgical Review, vol. v. p. 245. 



1852.] Medical Pathology and Therapeutics. 223 



blood-mass may pass away as albumen in the stools. As a means of cutting 
these discharges short, he strongly recommends iodine clysters ; which, in 
recent cases, may at once arrest the progress of the disease, and in all diminish 
the number of stools, and normalize their condition, whatever the individual 
peculiarities of the case maybe. From five to ten grains of iodine, and as much 
iod. pot., are administered in two or three ounces of water, from two to four 
times a-day — twice daily usually sufficing. If the rectum is too irritable to 
retain it, ten or fifteen drops of tr. opii are to be added, and a mucilaginous 
vehicle substituted for water. In spite of unfavourable conditions, so constantly 
successful did Dr. Eimer find this remedy during an epidemic, that he believes 
the disease will, as a general rule, be found curable by it, if it be resorted to 
before the organic changes in the intestine have advanced too far, exhaustion 
become too considerable, or important complications set up. In some slight 
cases it was employed alone. Generally, a simple oily emulsion was also ad- 
ministered, and sometimes acetate of lead and opium. — B. and F. Med.-Chirurg. 
Rev., April, 1852, from Heiile's Zeitschrift, Band x. p. 238. 

15. Starch in Cutaneous Diseases. — M. Cazenave has lately employed, largely, 
powdered starch, pure or mixed with oxide of zinc or camphor, in various dis- 
eases of skin. In acute eczema, impetigo, herpes, acne rosacea, after washing 
the parts with a weak alkaline solution, and well drying them, some of the 
following powder is sprinkled, viz.: Oxide of zinc, one part; starch powder, 
fifteen parts. In prurigo of the axillse, the anus, or the genitals, a quarter part 
of camphor is added. — Med. Times and Gazette, May 22, 1852, from L' Union 
Me'dicale. 

16. Solution of Nitrate of Silver in Pruritus of the Genital Organs. — Winter- 
nitz has lately recommended a solution of nitrate of silver (grs. iii ad ^i aquge) 
in pruritus of the vulva or scrotum. The solution is applied three times daily, 
and two cases are given in which it succeeded after a fortnight's trial, when all 
other means had failed. — Ibid., from Zeitschrift der Gesell. der Arzte zu Wien. 

17. Cauterization of the Glottis in Whooping- Cough. — M. Joubert has pub- 
lished the results of his experience of this mode of treating whooping-cough. 
He has treated in all 98 cases in this manner, but he excludes 30 of these as 
not being worthy of reliance. The remaining 68 cases he divided into three 
series, according to the period at which the treatment was commenced. Of 
these, the general results were, that in 40 the cure was rapidly effected, in 21 
a marked relief was experienced, and in 7 cases only the treatment failed alto- 
gether. — Prov. Med. and Surg. Joum., May 26, 1852. 

18. On the Hemorrhagic Diathesis. — Dr. Lange has recently contributed an 
interesting paper on this affection, containing the tabulated results of an ex- 
amination of the history of one hundred and forty examples. It has hitherto 
been only met with in the northern hemisphereo, ccurring in America between 
30° and 45° north latitude, and in Europe between 45° and 60° north latitude. 
Germany is among the countries most liable to it, and especially so along the 
course of the middle Rhine and the Maine. The coasts are far less liable than 
are inland regions. The inhabitants of mountainous districts are less liable 
than those of plains traversed by rivers. Vine countries are very liable. 

The subjects of the disease do not attain great age ; for among one hundred 
and forty examples, only nine were aged more than fifty ; the female sex seem- 
ing to possess less power of endurance than the male. The causes giving rise 
to the hemorrhage have usually been insignificant, as, e. g., scratches, cuts, 
leech-bites, extraction of teeth. When the bleeding is spontaneous, that from 
the nose is most frequent and oftenest fatal. Vomiting of blood is much more 
rare ; and, it is remarkable, that only one of the fatal cases arose from hcemop- 
tysis — the disease indeed seeming to have no affinity with tuberculosis. In one 
case vaccination gave rise to profuse bleeding, without, however, preventing the 
rising of the vesicle. The statement of Fordyce and others, that deep wounds 



224 



Progress of the Medical Sciences. 



[July, 



"bleed less freely than superficial, is not confirmed ; but the healing of all kinds 
of wounds is very tedious, although gangrene seldom occurs. 

The disposition to hemorrhage sometimes first shows itself during the first 
weeks of life, hut usually during the first or second year, the latest period in 
these tables being the eleventh year. The earlier the hemorrhage exhibits 
itself, the earlier, as a general rule, does death occur. At a later period the 
inclination to hemorrhage usually manifests itself aspetechige and ecchymoses. 
Accessory diseases do not, as, a priori, it might have been expected they would, 
pursue a more dangerous course in these subjects, excepting when those of the 
respiratory organs excite epistaxis. The duration of the attacks is very differ- 
ent, this being, perhaps, on an average, ten or twelve days — spontaneous bleed- 
ing usually continuing longer, but being better tolerated than traumatic. The 
effect of season is not determined ; but the bleeding seems to occur oftenest in 
spring and autumn. The blood is thin, and deficient in coagulability. In the 
majority of instances, the intellectual powers of these patients are of a high 
order ; and in most of them the colour of the eyes is blue, the complexion fair 
and delicate, and the hair light. Usually the constitution is strong, and the 
muscular system is often powerful and developed. In certain cases, the radial 
artery has been observed to be transparent in some spots, owing to the defi- 
ciency of the fibrous coat — confirming Rokitansky's view, that the disease con- 
sists in a remarkably delicate construction and vulnerability of the vessels, and 
a watery condition of the blood. The cholerico-sanguineous temperament pre- 
vails, and so-called rheumatic pains are very constantly observed. Spots of 
ecchymosis, often absent, may, when present, be either spontaneous or traumatic, 
the latter being usually much larger than the former. They change in colour, 
as after an ordinary contusion. Sometimes the ecchymoses stand in a critical 
or antagonistic relation to other affections ; thus, e. g., they may disappear on 
the advent of a paroxysm of gout, and reappear at its termination. In some 
hemorrhagic families, they constitute a lower form of the disease in certain of 
the members. Traumatic ecchymosis may be produced by strong muscular 
exertion, by falls, or even pressure. It usually disappears unaided, though 
requiring a longer period than the spontaneous ; and, if opened, it gives rise to 
dangerous hemorrhage. 

According to the tables, no difference seems to exist as to condition of life, 
or residence in town or country. The influence of hereditariness is only im- 
perfectly indicated. The mortality from the disease seems to be greatest be- 
tween twenty and thirty, and then diminishes. The earliest age at which it 
has been known to cease spontaneously has been between twenty-five and 
twenty-eight. Commonly disease of the liver, hemorrhoids, gout, or rheumatism, 
supervenes, and the influence of art is of little use. In palliating the affection, 
a certain time must always be allowed for the blood to flow, or congestion of 
internal organs is produced ; and, in such cases, where fhis precaution has 
been neglected, dry cupping of the extremities should be resorted to. Gene- 
rally, the bleeding stops of itself ; but only when exhaustion has occurred. 
Compression is of little use ; and, among the styptics, sulphuric acid, muriated 
tincture of iron, and a spirituous solution of sal ammoniac, are the best. Cau- 
teries and caustics usually fail. — B. and F. Med.-Chirurg. Rev., April, 1852, 
from Schmidt's JoJirbucli, vol. lxx. p. 35. 

19. Spontaneous Development of Gas in the Blood as a Cause of Sudden Death. 
— In the Presse Medicate de Bruxelles is published a memoir on this subject, by 
M. Durand Fardel. The case which forms the basis of the memoir is that of 
a lady, aged 56, who, being at Yichy with her husband, proceeded, as is the 
fashion, to take the baths, though there was no necessity for them as regards 
her general state of health, which, on the contrary, was remarkably good. It 
appears that on July 20, 1850, she took her second bath at four A. M. She had 
been over night in her usual state of health. In walking to the baths she 
noticed that her breathing was shorter than usual, and the attendant observing 
her condition advised her not to bathe that day. She, however, did so, and 
remained in her bath half an hour. When she got out she felt uncomfortable, 



1852.] 



M edical Pathology and Therapeutics. 



225 



and in a few minutes sank exhausted into a chair. Eespiration now "became 
very difficult, and in a few moments she was dead. 

M. Durand Fardel, who was on the spot immediately, found her still covered 
with her bathing sheet. The face was pallid; lips violet ; no froth on the lips; 
limbs flaccid ; and heart's action completely ceased. 

The autopsy was made twenty-two hours after death, the 31st of July, at three 
o'clock in the morning. The body presented no appearance of putrefaction, 
there being some lividity only on the depending portion of the trunk and mem- 
bers. The heart was very large ; the right cavities distended with liquid blood, 
rather violet-coloured than black, syrupy, very frothy ; the bubbles of gas in- 
closed were some (very numerous) as big as the head of a pin, others less common, 
as large as peas. When pressure was applied over the course of the two venae 
cavse, the blood which flowed into the right auricle was frothy, like soap and 
water; the parietesof the right cavities of the heart presented a superficial violet 
colour; the left side was completely void of blood, and not coloured; the left 
ventricle was considerably hypertrophied ; the orifices of the heart did not pre- 
sent any appreciable alteration, as also the aorta. All the abdominal venous 
system was distended with violet and frothy blood ; numerous bubbles of gas 
were also found in the blood of the splenic and portal vein. The lungs filled 
the chest, presenting a few adhesions, and some appearances of emphysema ; 
their colour was reddish outside, but of a deeper tint internally, where they 
presented traces of considerable sanguineous congestion, without infiltration of 
blood. There was considerable frothy congestion in the more depending parts. 
The bronchi contained some whitish frothy mucus. The abdominal organs pre- 
sented nothing more worthy of notice than a considerable sanguineous congestion 
of the liver, spleen, kidneys, and a remarkable congestion of the veins of the 
epiploon and mesentery. The epiploon was loaded with fat ; the stomach rather 
large, and containing about half a glass of clear colourless mucus. The intes- 
tines were not opened. The encephalon did not present the same degree of 
congestion as the other organs ; the sinuses of the dura mater contained only 
a little "liquid blood, not frothy. The brain and origin of the spinal marrow, 
examined as soon as possible, appeared completely natural, a little injected with 
blood ; no bubbles of gas appeared in its vessels. 

The author publishes this case in all its details, as science possesses as yet 
very few cases of this kind. The observations of Morgagni, wanting in details, 
do not allow of a positive judgment. M. Reyrolles, in two cases of death by 
hemorrhage, found the blood frothy in the heart and veins. 

Finally, M. Ollivier, of Angers, published a case {Ann. Gin. de Med., 1838) 
which leaves no doubt as to the existence of the disease which M. Durand Fardel 
observed in this case. A curious circumstance, doubtless observed before, 
enabled M. Durand Fardel to state the existence of gas at the moment even of 
death. The bleeding performed at the arm gave issue for more than a quarter 
of an hour to blood, which, trickling from the vein of a body deprived of life, 
carried with it numerous bubbles of gas. 

To what cause can the origin of this gas be attributed? This is a question 
still undetermined, and which may be perhaps solved at some future time by 
the chemical analysis of the gas found in the blood. Whatever it may be, the 
observations of M. Durand Fardel tend to prove that it is owing to a sponta- 
neous exhalation from the veins, caused by spontaneous alteration in the crasis 
of the blood, of which we are ignorant. 

[This case is still further important in its connection with those cases of sud- 
den death after delivery in which air has been found in the blood, and is sup- 
posed to have entered by the uterine sinuses. May it not in these cases depend, 
as in M. Fardel's, on a spontaneous generation of gas ? — Ed. P. J.] — Prov. Med. 
and Surg. Journ., April 14, 1852. 

20. Infantile Phlebitis, with Purulent Deposits, Erysipelas, and Jaundice, arising 
from Inflammation of the Umbilical Vein. — Dr. W. B. Herapath records {Lond. 
Journ. Med., May, 1852) the following interesting case : — 

Mrs. J. was delivered, Feb. 24, 1852, of her first child, a healthy male. _ The 
labour was comparatively an easy one ; everything proceeded perfectly satisfac- 



226 



Progress of the Medical Sciences. 



torily until the sixth day after delivery. A slight hemorrhage took place from 
the umbilicus at the period of the separation of the shrivelled remains of the 
funis, but this would not have been considered worthy of remark, had not other 
important symptoms subsequently developed themselves. 

March 3d. Some signs of uneasiness ; griping and gastric disturbance ap- 
peared ; the evacuations were scanty and unnatural, consisting chiefly of cur- 
dled milk. Vomiting was also present. Castor oil was ordered. 

4th. The child improved under the treatment. 

6th. As the above-named symptoms reappeared, the oil was again ordered ; 
and as constipation existed, a larger dose was used and again repeated. A car- 
minative was also prescribed, to expel flatulence from the stomach. 

7th. The evacuations very scanty, deficient in bile, and chiefly consisted of 
curdled milk. The two doses of oil had only produced one movement. I 
ordered one grain of calomel and four of rhubarb ; and directed them to be 
repeated in the morning, if necessary. 

8th. Both powders were given, and some evacuations, having a more healthy 
appearance, resulted. The infant was considerably better. There were occa- 
sional spasmodic pains, accompanied by retraction of the limbs : slight shivering 
and moaning also occurred occasionally. The child was far from easy, but I 
did not see much to excite alarm. 

10th. The nurse called on me to say that the child had become much worse, 
and "that it appeared swollen all over." Upon visiting it, I found that erysi- 
pelas had developed itself upon the index finger of the right hand, and also in 
the corresponding finger on the opposite side. A slight blush of erysipelas also 
appeared upon the second toe of the right foot: the knee was tumid, tender, and 
hot, but not erysipelatic. The little infant appeared to be in considerable pain ; 
was almost constantly crying or moaning ; vomiting often, with frequent hic- 
cough; it was feverish, refused the breast, and scarcely slept at all. The 
bowels were somewhat tumid, and presented a general tympanitic appearance. 
The umbilicus was perfectly sound and healthy ; there was no hernia. I ordered 
an evaporating spirit lotion to be constantly applied to the inflamed and ery- 
sipelatous spots, and another dose of castor oil to be administered. 

The occurrence of erysipelas in this case was entirely without any apparent 
exciting cause, and at first was inexplicable. The mother was in good health ; 
the apartment was free from currents of air, in fact, warm, without being desti- 
tute of ventilation ; the child had never been removed from it, and it had been 
carefully and attentively nursed. The appearance, however, of erysipelas in 
some measure accounted for the other anomalous symptoms. 

11th. The child was decidedly worse. The erysipelas extended upwards to 
the elbow on the left side; the fingers were considerably enlarged, and very 
red ; there was a puny swelling just about the right sterno-cleido-mastoid, very 
tender to the touch ; icterus plainly exhibited itself, the conjunctivae were orange 
yellow, and the skin, where free from the erysipelatic blush, was generally 
yellow. This was not the case yesterday, but it came on during the night ; the 
respiration was peculiarly hurried, short, and sometimes irregular, and sigh- 
ing, but there was no cough or bronchitic rale ; the pulse was rapid, flutter- 
ing, and weak ; slight evidence of fluctuation was observed on the right finger. 

In pondering over this strange combination of symptoms, the peculiar character 
of the erysipelas struck me ; the rapid scattering of the disease, in fact, the 
co-existence of the erysipelas at various points of the system, appeared very 
marked ; it had not that erratic disposition which that disease usually assumes. 
These, together with the manifest existence of pus about the finger joints, led 
me to imagine the entrance of pus into the system, whilst the presence of jaun- 
dice appeared to point to the liver as the chief part implicated ; and it occurred 
to me that there was a general cause acting on the whole system, and I gradu- 
ally came to the conclusion that phlebitis of the umbilical vein had produced a 
purulent fluid, which, entering the circulation, caused the peculiar combination 
of symptoms which rendered the case so interesting. I at once expressed my 
opinion to the parents and nurse, as to the nature of the case, as well as my 
conviction that the little patient would not survive ; but in order to make an 
attempt to save it, iodine was applied freely over all the erysipelatous points. 



1852.] 



Medical Pathology and Therapeutics. 



227 



The lotion was ordered to be continued constantly; and a few grains of gray 
powder were prescribed, together with an anodyne carminative mixture, to be 
frequently administered in small doses. 

12th. At two P.M., the patient was evidently much worse, and was sinking 
rapidly. The erysipelatous redness had disappeared, giving place to a dingy 
purple, or livid colour. The icterus had increased in intensity ; the tempera- 
ture of the surface had much decreased, and the extremities were cold ; respira- 
tion was becoming embarrassed, very irregular, gasping, and accompanied by 
a mucous rattle, whilst the mental faculties were wrapped up in a decided coma, 
and the eyes were glazed and open. Occasionally the child would partially 
arouse itself and moan piteously, but it was not sensible to external impressions 
of light or sound. The hiccough had become very frequent ; and the pulse 
scarcely perceptible from its debility, and also very rapid. Occasionally the 
colour of the infant would undergo a considerable change, the countenance 
becoming suffused with a livid purple, around the eyes and mouth being of a 
deeper tint. These symptoms gradually increased in severity, the respiration 
becoming still more embarrassed, and at length about eight P. M. it expired, 
in slight convulsions. Having represented the extraordinary nature of the case 
to the parents, they kindly consented to a post-mortem examination, at which 
my friend Mr. Parsons (to whom I had stated the nature of the diagnosis formed) 
was present. 

\?>th. Post-mortem Examination. — The whole surface of the body was of a 
deep orange-yellow colour; also the conjunctivae. Collections of pus existed 
at all the erysipelatous points ; about three drachms escaped upon making a 
puncture with a scalpel upon the inside of the right knee. At the second joint 
of the left index finger a similar puncture was also made, and a teaspoonful of 
thick yellow pus escaped. It was beneath the integuments only, and not in 
the joints, in either case. About two or three drops issued upon incising the 
toes, in the same way. Upon cutting through the integuments at the usual 
position for examination, a purulent deposit was opened at the clavicular arti- 
culation on the right side. This was superficial, being situated beneath the 
layers of fascia underneath the platysma myoides, and between the sternal and 
clavicular attachments of the sterno-cleido-mastoid. It did not appear to be 
in any distinct sac, but below it was bounded by the junction of the fascia to 
the clavicle ; above, the probe would pass easily in the direction of the muscle, 
and pus had evidently taken the same course. About two drachms of pus were 
found in this situation. The umbilicus was perfect, and the cicatrix sound ; 
the umbilical vein was large, and rounded. Upon cutting it across, within the 
integuments, it was found to be pervious through its whole length, and filled 
with a curdy purulent fluid, which became more purulent as the vein was traced 
backwards to the liver. There were not any purulent deposits in this viscus, 
but it was everywhere congested and of a uniform colour. The gall-bladder 
contained merely a few drachms of transparent, colourless, viscid mucus ; its 
duct appeared impervious from some cause. Upon tracing the hepatic branches 
of the vena porta, they were found to contain pus, even to some of their smaller 
subdivisions, both in the right and left lobes. These appearances, however, 
were not general. Two main branches and their ramusculi were principally 
thus diseased ; one on the right, and the other on the left. The greatest por- 
tion of the pus had found its way to the right auricle through the vena cava 
ascendens, which of course is but a continuation of the trunk of the umbilical 
vein. Some slight coagula were found in the auricle and ventricle. The pul- 
monary artery was obstructed by tolerably firm coagula. The lungs were car- 
nified, but of a more florid colour than from hepatization, and appeared to 
resemble the lungs of an infant still-born. The inferior lobes, as well as one 
of the superior, were solid and did not crepitate ; the other lobes were crepitant, 
but congested ; no purulent deposits, however, were found, although carefully 
sought for. The foramen ovale was still pervious, although it had progressed 
towards obliteration. The opening was bounded by two curved margins, the 
superior being more deeply curved than the inferior ; the long diameter was 
antero-posterior, taking the usual position of the heart into consideration, and 
measured one-fifth of an inch. The superior-inferior diameter was one-seventh 



228 



Progress of the Medical Sciences. 



of an inch. The ductus arteriosus was impervious, but the obstacle to the 
passage of a probe through it was very slight indeed, and it was contracted and 
indurated. The left cavities of the heart contained some coagula, dark in colour, 
and rather firm and stringy. The thymus was not of unusual size, or otherwise 
abnormal. 

Remarks. — The post-mortem examination fully bore out the diagnosis made 
during the life of the little patient, in every respect, as far as the nature and 
cause of the disease were concerned ; but I had certainly expected to find exten- 
sive purulent deposits in the liver and lungs. These organs, it is true, exhibited 
the early signs of purulent absorption, but they had evidently suffered less from 
the pyoheemia than usual. The current of purulent blood had found its way 
to the right auricle through the vena cava, without much troubling the hepatic 
circulation. It had here split into two portions : one, the minor, going to the 
lungs, and inducing solidification ; the other, and greater, passing through the 
foramen ovale to the left auricle and ventricle to the aorta, whence it proceeded 
through the systemic circulation, and produced the local deposits found in the 
capillaries of the extremities, etc. The open condition of the foramen was not 
speculated upon, and overlooked until found at the post-mortem examination ; 
but when discovered, it at once cleared up all difficulties. Had this aperture 
been closed, the intensity of the disease would have been shown in the lungs 
and liver without doubt; in the former principally, as the pus would have fol- 
lowed the course of the circulation : the liver also would have suffered, but in 
a minor degree, inasmuch as after birth the umbilical vein does not carry any 
blood into the vena porta. 

In this instance, the phlebitis appeared to have crept along the lining mem- 
brane of the veins to some of the ramifications of the vena porta, and to have 
generated pus in its progress. These globules were then washed by the current 
of blood into the hepatic portal capillaries ; and they would have induced de- 
posits, had the infant lived a few days longer to give time for the development 
of pus, according to the physiological laws of its genesis, from the multiplication 
of its nuclei and nucleoli. 

The umbilical vein was brought home, and its contents submitted to micro- 
scopical examination. Pus-globules were detected, and the existence of softened 
fibrin was also recognized by the action of reagents. 

21. Vaccination tested by the Experience of half a Century. — This is the title 
of a paper read before the Koyal Medical and Chirurgical Society, on the 9th 
of March last, by Dr. George Gregory. The author commenced by observing 
that variolous inoculation was first heard of at Constantinople in 1700, but was 
not practised in England till 1721, and did not become general till 1750. In 
1746, the Smallpox and Inoculation Hospital was established; and from this 
period variolous inoculation made favourable progress in the good opinion of 
the public throughout England. In France, however, during the same period, 
it met with neglect, notwithstanding the efforts of De La Condamine to 
convince his countrymen of the merits of inoculation ; and prejudice extended 
so far, that the parliament of Paris, in 1763, prohibited the practice of variolous 
inoculation within the walls of that metropolis. The author then proceeded to 
notice the twofold object with which inoculation was performed — first, to banish 
from the mind all anxiety as to the taking of smallpox in after-life, by giving 
it at once ; and, secondly, to insure'a mild form of the disease, free at least from 
secondary fever. Inoculation was eminently successful in fulfilling and attain- 
ing these objects. Nevertheless, it undoubtedly had its disadvantages; it was 
essential to practise it in early life, before the infantine constitution could be 
known ; and it thus often lighted up the dormant embers]of scrofula. In 1798, 
the practice of variolous inoculation had been tested by the experience of half 
a century. In this year Jenner published his first treatise on Vaccine Inocula- 
tion, the advantages of which were at once confidently proclaimed ; and in the 
following year seventy-three of the most eminent physicians and surgeons of 
the metropolis had signed a document, purporting " that persons who have had 
the cowpox are perfectly secure from the future infection of the smallpox.-" 
The first claims of Jenner in favour of vaccination were singularly modest; but 



1852.] 



Medical Pathology and Therapeutics. 



229 



in 1802, he announced to the House of Commons — first, "that vaccination is 
attended with the singularly beneficial effect of rendering, through life, the 
person so inoculated, perfectly secure from the infection of smallpox;" and, 
secondly, " that vaccination had already checked the progress of the smallpox, 
and, from its nature, must finally annihilate that dreadful disorder." The quan- 
tity of smallpox that still prevails, and the practice of revaccination, almost 
universal, lead to the conclusion that these broadly urged claims in favour of 
vaccination have not been substantiated. Fifty years have passed since Jenner 
petitioned Parliament; and the author proposed, by the experience of this half 
a century, to test the merits of vaccination. But first, what is understood by 
vaccination '? Something prophylactic of smallpox : or something identical with 
smallpox ? Cowpox is a disease sui generis, and it cannot be said that he who 
has undergone vaccination has had smallpox in a mild form. A certain rela- 
tionship exists between the two ; but though variola by passing through the 
cow becomes cowpox, yet cowpox has never, in its turn, been converted into 
smallpox. Cowpox and smallpox are, at all times, and in all countries, clearly 
and readily distinguishable. The object of inoculation was to give the disease 
of smallpox, not to prevent it. The object of vaccination is to prevent, not to 
give, smallpox. Recurring smallpox, and smallpox after vaccination, are not 
merely different from each other, but actually opposed to each other. " If a 
person inoculated in childhood contracts smallpox in adult life, he suffers small- 
pox a second time, but a person taking smallpox after vaccination, takes the 
disease for the first time." The enemies of inoculation, as well as the sup- 
porters of vaccination, had severally taken their stand on recurrent or second- 
ary smallpox. De La Condamine declared that not one person in 10,000 ever 
took smallpox a second time. The fate of Louis XV. was alluded to, and it was 
shown that the king's disease in early life (1724) was not smallpox, but a sharp 
yet brief attack of fever ; that, living in the constant dread of smallpox, his dis- 
trust of inoculation was fearfully chastised by his death under a most aggra- 
vated attack of confluent smallpox. The author then noticed the extreme rarity 
of recurrent smallpox. The Transactions of the Society, extending through a 
period of forty-seven years, contained only one solitary case of recurrent small- 
pox. In many cases of so-called secondary smallpox, the evidence of antecedent 
variola could not be relied on, as a case narrated in the Edinburgh Medical and 
Surgical Journal, Oct. 1818, clearly established. Many of the cases which the 
author had inquired into were equally undeserving of credit. To arrive at a 
trustworthy conclusion, the details of both attacks should be carefully given. 
Very few medical men have in such cases witnessed both the primary and 
secondary seizure, and the author emphatically expresses himself as thoroughly 
convinced that the recurrence of smallpox is among the most rare events in the 
annals of medicine. The author then contrasted the occurrence of smallpox 
after vaccination. The records of the Smallpox Hospital throw much light on 
this subject. The following is a summary of the statistical details appended to 
the paper: During the last eleven years, 4092 persons have been admitted into 
the hospital, having smallpox, of whom 2168 had been vaccinated, and 1924 
were unvaccinated ; more than one-half of those admitted had been vaccinated 
in early life. The majority were of adult age, a few between 9 and 15 ; but 
below the age of 9 scarcely any vaccinated person was admitted. It would thus 
appear that the susceptibility to the variolous miasm among vaccinated persons 
increases as life advances. The reverse of that happens in the unvaccinated. 
In 1850-51, the total number of cases of smallpox admitted was 976, of whom 
162 died, being at the rate of 16 per cent. Of the 976 admitted, 41 were infants 
below the age of 5, all unprotected, of whom 22 died ; 101 were children between 
5 and 15, majority unvaccinated, of whom 25 or one-quarter died ; 685 were 
adults from 15 to 30 ; 109 beyond that age. Total, 794 adults ; the larger pro- 
portion of these had been vaccinated, of whom 115 died, or 14 per cent. Of the 
total number admitted, 976, 613 professed to have been vaccinated; 569 exhi- 
bited cicatrices ; of this latter section, 25 died, being at the rate of 4 per cent. 
In 1851, the proportion of persons admitted after vaccination amounted to 65 per 
cent. : it was only 44 per cent, in 1841. The increase is attributable to the 
extensive diffusion of vaccination. The mortality at the Smallpox Hospital, 



230 



Progress of the Medical Sciences. 



[July, 



during the last two years among the well-vaccinated section, has only slightly 
exceeded 4 per cent. The experience of half a century abundantly demonstrated 
that smallpox, though it has been largely controlled, will always abide among 
us, and that the notion of extirpating it is absurd and chimerical; and while 
acknowledging the immense benefits which hare accrued from the splendid dis- 
covery of Jenner, vaccination had failed in establishing in the mind a confident 
feeling of security: it must be viewed as a beneficent provision of Nature, not 
for the extermination, but for the mitigation of smallpox. The author proceeded 
to show that inoculation had been abolished by Act of Parliament, in 1840 ; and 
that, though rigidly observed, smallpox was just as prevalent now as then ; that 
the quantity of smallpox had not in the smallest degree been affected by the 
prohibitory clauses of that act; that, while this act prohibited inoculation, it did 
not render vaccination compulsory. Numbers therefore remained, as a pabulum 
whereon smallpox might prey. If the legislature could not or would not enforce 
vaccination, the restriction on inoculation should be removed. TTith proper 
precautions, inoculation might be safely adopted. Practised by other than 
authorized medical practitioners, it would of course be punishable as a misde- 
meanour by fine and imprisonment. With such restrictions it might be prac- 
tised with perfect security. By far the larger proportion of mankind would 
continue to adopt the mild and safe process of vaccination ; while others would 
prefer that measure which, occasioning a greater amount of immediate, abolished 
all prospective anxiety. Educated as the present race of medical practitioners 
were, and acting, as they would act. under the supervision of a discerning press, 
both public and professional, they would exercise their judgment to the entire 
satisfaction, and ultimately to the great and permanent benefit of the country. 

Mr. Grainger said he wished to explain the reasons which had induced him 
to take a part in the present discussion. It was doubtless known to many pre- 
sent that the Epidemiological Society had appointed a committee to investigate 
the important subject of vaccination and smallpox, of which it happened that 
he was chairman. The committee had collected some very important evidence 
and facts; they had received the opinions and experience of a large number of 
medical practitioners in different parts of England : and it was deemed essential 
that some of the more important results should be made known on the present 
occasion; and he was requested to act as the organ of the committee. He had 
also, at the request of the General Board of Health, made an inquiry two years 
ago into the state of vaccination in the metropolis : and an additional reason 
for speaking was the deep interests involved in regard to the public health. 
Mr. Grainger proceeded to remark that, although he had no practical acquaint- 
ance with the subject, and would not for an instant place his own judgment, as 
regarded the special points of the investigation, in competition with that of Dr. 
Gregory : yet that as this was a question resting essentially on evidence and 
facts, any one accustomed to deal with such inquiries was competent to take 
part in the discussion. It was obvious that the important points raised by Dr. 
Gregory could not be determined by any amount of hospital experience ; and 
yet it appeared that a considerable part of the data relied on were derived from 
the Smallpox Hospital. The statistics of that institution, therefore, became 
important. The following table is from a paper of Dr. Gregory's, in the Medical 
Times for 1849 :— 

Pereentnee 

Total. Deaths. of Deaths. 

Unprotected cases 254 103 40 

w . , A f with cicatrices . . 365 38 10 

Taccmated (without do. . . 63 25 39 

Total vaccinated 428 63 14 

Previously inoculated .... 3 1 33 

It is important to notice that in 28 out of 168 deaths, one-sixth of the whole, 
there were symptoms of superadded hospital disease, especially erysipelas faci- 
alis ; and the weekly returns of the Registrar-General proved that these super- 
added hospital diseases still continued. Now, it is impossible to doubt that the 
state of things which induced so much evil must have operated most injuriously 



1852.] 



Medical Pathology and Therapeutics. 



231 



on the whole of the patients ; that cases which would have been mild became 
severe ; that those which would have been discrete became confluent, and that 
thus the general mortality was much raised. The following evidence, taken 
without selection from thirty returns received from medical practitioners, shows 
a very different result : — 

Percentage 

Total. Deaths. of Deaths. 

Natural smallpox in unprotected . 1731 361 20.85 

Smallpox after vaccination . . 929 32 3.44 

In an important report of the "Norwich Board of Health," on a severe epi- 
demic of smallpox, which occurred in that city in 1845, it is stated that the mor- 
tality from smallpox in the unprotected was 12J per cent., and in the vaccinated 
only 3 per cent. ; and investigation rendered it doubtful, in the latter class of 
cases, whether all had been properly under the influence of cowpox. The same 
report gives the results of the personal visitation of 531 families, comprising 
2170 individuals. Of these, 1664 had smallpox, of whom 1536 had not been 
vaccinated, while of 506 who escaped, only 84 had not been vaccinated. In the 
last number of Dr. Copland's Dictionary of Practical Medicine, it is stated that, 
after half a century has elapsed since the discovery of vaccination, "the middle 
of the nineteenth century finds the majority of the profession in all latitudes 
and hemispheres doubtful as to the preponderance of advantages, present and 
prospective, to be obtained either from inoculation or from vaccination." In 
reply to this assertion, and as having an immediate bearing on the present dis- 
cussion, he would state that 430 replies to the questions issued by the Epide- 
miological Society, with the object of ascertaining the opinion of the profession 
on the subject of vaccination, had been carefully examined by Dr. Seaton ; and, 
be it observed, without selection : and of this large number of medical practi- 
tioners, one only had expressed any doubt of the protective power of vacci- 
nation; and this one doubt only amounted to this — that, having been himself 
inoculated in infancy, this gentleman felt more secure than if he had been vacci- 
nated. Having this concurrent testimony in favour of vaccination, he must 
say that Dr. Copland, in his opinion, had hazarded a very strong statement on 
very insufficient grounds. He might add that he had examined a large number 
of the annual returns made by medical officers to the poor-law board, and that 
he had not found a single expression indicative of doubt on this point. The 
gentlemen at that board whose duty it was to inspect the annual returns re- 
ceived from every union in the kingdom also stated that he had in no one instance 
seen any adverse opinion recorded. It is, however, obvious that this great ques- 
tion, involving not only the happiness and welfare of the people of this country, 
but of the world at large, must be finally settled by an appeal to facts and to 
the experience of long periods resting on large data. Dr. Waller Lewis had 
prepared the following table, showing the decline of smallpox in London from 
1750 to 1850, taken from "Marshall," and other records in the office of the 
Kegistrar-General : — 

Average of deaths from smallpox in London per 1000 deaths, for the ten years 
ending 1752, 89 ; for the ten years ending 1756, 95 ; for the ten years ending 
1770, 108; ditto, 1780, 107; ditto, 1790, 94; ditto, 1800, 77; ditto, 1810, 63; 
ditto, 1820, 41 ; ditto, 1830, 32; ditto, 1840, not known ; ditto, 1850, 16. Ave- 
rage number of deaths from smallpox per annum in London for the ten years 
ending 1750, 2036; for the ten years ending 1850, 498. 

The number of deaths from smallpox in the former period is to the latter as 
4 to 1, while the population of the former period was to the latter probably as 
1 to 4. 

Dr. Lewis had also drawn up a table, showing similar results in Prussia. 
Mortality from Smallpox. 

In Bemjx (Caspar's Medical Statistics). 
Total Smallpox 
Deaths. Deaths. 

1783— 1791=8 yrs. . 47,367 4315 
1814—1822=8 " . 51,389 535 



Per 1000 

Deaths. Eatio. 

91 10 

10.5 1 



232 



Progress of the Medical Sciences. 



[July, 



In ail Prussia (Official Statistical Cables for 1S49). 

j Total Smallpox Per 1000 

-/ Deaths. Deaths. Deaths. 

In 1825 . 327,354 1893 5.8 

" 1834 . . . . . 424,013 6625 15.6 

" 1843 444,573 4508 10.2 

" 1849 498,862 1760 3.5 

In the Eeglement Berlin, Oct. 31, 1803 (containing the regulations for medical 
and other public offices, in respect of vaccination), it is said that smallpox 
caused, on an average, 40,000 deaths a year in Prussia. Prussia had at that 
time a population of ten millions. In 1849, among a population of more than 
sixteen millions, smallpox killed 1760 persons. Therefore, smallpox was thirty- 
seven times more fatal in Prussia, in 1803, than in 1849. 

The high mortality shown in these tables, prior to the discovery of vaccina- 
tion, applies, it should be remembered, to that period of the last century in 
which, at least in England, the practice of smallpox inoculation, which it is now 
suggested should be revived, had been very actively carried out ; and these are 
the results. He would now state the experience of 435 medical practitioners, 
relating to themselves personally, and therefore affording most reliable evidence. 
Of these 435 gentlemen — 

Had been vaccinated, much exposed to smallpox, and escaped . 266 

Vaccinated, not much exposed, and escaped .... 34 

Vaccinated, and taken smallpox 38 

Inoculated, and escaped smallpox 69 

Inoculated, but have taken smallpox 5 

Inoculated, and taken cowpox accidentally .... 3 

Neither vaccinated nor inoculated, and have taken smallpox . 20 

With the exception of two, all the cases of smallpox after vaccination were 
"mild." In the five cases of smallpox after inoculation, one is described as 
very severe. As so much has been said of the frequency of smallpox after vac- 
cination, and of the great mortality in such cases, the results obtained from the 
examination of 356 replies sent to the Epidemiological Society, are of great 
value — 

182 state expressly that tliey have never seen a death from smallpox after 
vaccination. 

3 state respectively that the cases have been "few," "very few," and 
" frequent." 

44 state their experience in numbers, and give an aggregate of 70 deaths. 
127 give no statement of their experience on the subject. 

The following table gives the experience of thirty practitioners on the respect- 
ive mortality of (1) Natural smallpox ; (2) Smallpox after smallpox ; (3) Small- 
pox after vaccination : — 

Percentage 

Cases. Deaths. of Deaths. 

Natural smallpox . . . .1731 361 20.85 

Smallpox after smallpox ... 58 22 37.92 

Smallpox after vaccination . . 929 32* 3.44 

In the replies with which the Epidemiological Society has been favoured, 
great stress is laid on the manner in which the operation of vaccination is per- 
formed ; on the importance of fresh and efficient lymph ; and on the careful 
watching of each case — precautions which it is certain are but too often neg- 
lected. He had received from Mr. Marston, the resident medical officer to the 
Smallpox Hospital, a statement highly to the credit of that institution, and pro- 
claiming, in unmistakable language, the importance of good vaccination. Mr. 
Marson states, that during the last sixteen years he had vaccinated about 40,000 
persons ; and that of this large number not one had subsequently come to the 
hospital with smallpox. Now, although many of these persons must have died 

* In seven of these, the evidence of vaccination was not satisfactory ; and in six others, 
the death is ascribed to superadded diseases. 



1852.] 



Medical Pathology and Therapeutics. 



233 



or quitted London, still the fact that none had up to this time been known to 
be attacked, was most important. Allusion has been made to the heavy mor- 
tality still caused by smallpox, the inference being that vaccination has failed 
to produce the great results anticipated by its advocates. It has been already 
plainly demonstrated that the mortality since the discovery of the illustrious 
Jenner has immensely diminished, especially where vaccination, as in Prussia, 
has been extensively diffused ; and if, as is but too true, many victims still are 
sacrificed in these kingdoms, it is due to the enormous neglect of vaccination, 
not to its failure. There is no point upon which it is more requisite to convey 
right information to the public than upon this ; and even as regards the profes- 
sion there is great need that the actual facts should be known. Although there 
are a National Vaccine Establishment, and acts of Parliament for promoting 
vaccination, there is nothing in this country deserving the name of a national 
system. The institution just named is merely engaged in supplying lymph; it 
has no power to secure vaccination. The Poor-law Board, which is charged 
with the administration of the act of 1840, has no means of knowing where vac- 
cination is neglected till the end of each year — consequently, when, as is con- 
stantly happening, attacks of smallpox have occurred and swept off its victims. 
Information is indeed furnished by the returns of the registrar-general of any 
severe attack of smallpox, but then, this is only known when it is too late — after 
the mischief has been done ; these are inherent defects in the act, and do not 
depend on the administrative body. He had, through the courtesy of the Poor- 
law Board, had an opportunity of examining, with Dr. Lewis, some hundred 
returns from all parts of England and Wales, and a few of the facts were set 
forth in the following tables : — 

Evidence of great neglect of Vaccination, as shown by the Number of Vaccinations 
under One Year of Age, and the Number of Births, for 1851. 









Percentage of 




Vaccinations. 


Births. 


Vaccinations. 


In 13 unions in London 


. 4641 


21,598 


21. 


In' 31 unions in the country . 


. 706 


7674 


9.2 


Teesdale .... 


70 


593 


11.8 


East Stonehouse 


1 


438 




Bideford .... 


22 


567 


3.8 


Welwyn .... 


4 


84 


4.7 


Hitchin .... 


85 


905 


9.4 


Xorthleach .... 


. 4 


339 


1.1 


Loughborough 


61 


968 


6.3 


Camelford .... 


1 


388 




Redruth .... 


. 378 


1925 


19. 


Kettering .... 


12 


644 


1.8 


Cardigan .... 


34 


531 


6.4 


Sarnford .... 


2 


447 




Ipswich (1850) 


56 


1153 


4.9 


Thingor (1850) 


10 


586 


1.7 


Arundel .... 





73 





Evidence of previous great neglect of Vaccination from the Excessive Xumeers 
of Vaccinations in One Year, as contrasted with the Births of that year. (From 



years 1850-51.) 

Total Vaccinations Births in 

in the Year. the Year. 

St. Alban's Union, 1850 151 562 

Do. 1851 1750 581 

Bromyard 1850 679 342 

Windsor " 1507 480 

Ross " 613 448 

Watford " 915 588 

Hatfield " . . . . .423 227 

Maldon " 809 678 

Tregaron " 557 301 

Do. 1851 405 308 

St. Asaph 1850 727 493 



234 



Progress of the Medical Sciences. 



[July, 



The last table is very instructive, as it shows what can be accomplished when 
the local authorities are alarmed by the prevalence of smallpox, or are stimulated 
by the remonstrances of the Poor-law Board. It is stated, in a report of that 
Board, that in 1848 the number of persons vaccinated under one year of age 
by the public vaccinators in the whole of England amounted to 33 per cent, of 
the total births ; and yet it is seen that in various unions not more than 2, 3, or 
4 per cent, are so vaccinated. But there is other evidence of the almost incre- 
dible neglect of vaccination. It is stated by Dr. Gregory, in his valuable Lec- 
tures on Eruptive Fevers, that, up to the age of eight years, "the protective 
power of cowpox may, for all practical purposes, be considered as complete." 
It may therefore be assumed that all those who perish under five years of age 
have not been vaccinated. In a very valuable report of Mr. Wilde, of Dublin, 
contained in the report on the census of Ireland for 1841. it is stated that of the 
56,006 deaths from smallpox which occurred in that country in the decennial 
period of 1831-41, no fewer than 79 per cent., or 45,824, were those of children 
under five years of age. In this country the ratio is pretty nearly the same ; 
thus, Dr. Gregory states, in his lectures, that of 9762 persons who died of small- 
pox in England, in 1837-38, the deaths under five years were 7340, or 75 per 
cent, of the whole. In facts like these, exhibiting not the failure, but the neg- 
lect of vaccination, is the true cause of that mortality of which we have heard 
to-night to be discovered. Although he regretted he was compelled, in the 
discharge of the duty imposed upon him, to trespass so long on the patience 
of the meeting, it was impossible he could sit down without alluding to the pro- 
posal that had been made that evening for the revival of variolous inoculation. 
It might be supposed, from the way in which that procedure had been lauded, 
that it was, under proper management, a safe and harmless measure ; but the 
experience of it in the last century gave very different results. In this country 
it was for a long time strenuously opposed by the profession as well as by the 
public ; and when at length it was sanctioned, the ravages of smallpox still 
continued, and to such an extent, that in the thirty years following the general 
use of inoculation, from 1770-1800, the deaths, in London, from this disease, 
amounted to 92 in 1000 from all causes. The Faculty of Medicine of Paris for- 
mally condemned inoculation; and so late as 1763, it was prohibited by a royal 
ordinance. In the interest of the public health, it is right and proper to inquire 
of those who would revive the practice of inoculation, what security they pro- 
pose, to guard the unprotected from the variolous poison, when it shall be dif- 
fused systematically over the country, and shall have penetrated and be main- 
tained in every nook and corner of the land ? To this question a precise answer 
should be given. It has been shown that at present there are multitudes of 
unvaccinated persons ; and it is certain that no law could enforce universal in- 
oculation ; so that if that practice, which has been wisely prohibited by the 
legislature, should ever be revived, there would be thousands of unprotected 
persons in all parts of the country, many of whom would become the ready 
victims of natural smallpox. It is deeply to be regretted that, at the exact time 
when strenuous efforts are about to be made by the Epidemiological Society to 
secure the more general vaccination of the people of this country, so earnestly 
desired by the profession and so essential to the common weal, doubts as to its 
protective power should be promulgated and made public. In one thing he cor- 
dially agreed with Dr. Gregory, and that was in the absolute necessity for a 
searching inquiry into the whole system of vaccination as at present conducted, 
the state of which was disgraceful to the country of the illustrious Jenner. It 
was a thing all but incredible, that in the short space of ten years, 45,000 child- 
ren were, in Ireland, allowed to be sacrificed at. the shrine of ignorance, preju- 
dice, and apathy ; when, as all parties admitted, not one need have perished, 
so far as smallpox was concerned, if only that great remedy, provided as it were 
by the hand of God himself, had been applied. — Lancet, March 20, 1852. 



1852.] 



Surgery. 



235 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

22. Curative Treatment of Aneurism of tlie Aorta. — "We reproduce such portions 
of a valuable practical essay on this subject, by Dr. O'B. Bellinghait, as most 
plainly set forth his mode of treatment. 

The indications of treatment in aneurism are — 

1. To diminish the distending force of the blood from within, by which the 
further enlargement of the sac will be prevented, and it will be placed under 
a favourable condition to contract. 

2. To endeavour to strengthen the parietes of the sac by favouring the 
gradual deposition in its interior of the fibrin of the blood which passes through 
it, by which the risk of its rupture will be diminished. 

3. To endeavour to maintain the continued deposition of fibrin in the sac, 
until it is filled, and no longer permits the entrance of blood. 

4. To bring about these results without deteriorating the quality of the 
blood, or diminishing too much the patient's strength. 

The plan of treatment which appears to be best calculated to fulfil the indi- 
cations in view is almost essentially dietetic. It consists in limiting the pa- 
tient, for a given period, to the smallest quantity of fluid possible ; in diminish- 
ing considerably likewise the solid aliment; in confining the patient at the 
same time to bed, and endeavouring to maintain the mind in as tranquil a state 
as possible. Dr. Bellingharti is neither an advocate for bleeding or purgatives 
(except occasionally, if required), nor for diuretics or digitalis, or any of the 
other medicines which have been used in this disease, with the exception of 
opium, and this only when sleep is prevented by pain. 

By confining the patient to the horizontal posture, the circulation is tran- 
quillized, and the heart's action becomes slower. When this is combined with 
a small quantity of solid nutriment, and a still smaller quantity of liquid, the 
heart's action will become slower, and the pulse compressible, small, and soft. 
Its effect upon the blood will be to render this fluid thicker, as the watery por- 
tions are excreted by the kidneys and skin. Thus, less blood will pass through 
the aneurismal sac, it will be transmitted with less force, and in a diminished 
stream, while its quality will be improved ; all which circumstances are favour- 
able to the deposition of fibrin in the aneurismal sac ; and as the muscles are 
not exercised, there is no waste of fibrin in supplying them. 

The diet constituted an important item in the treatment of aneurism advo- 
cated by Albertini and Valsalva, where a very low diet was combined with 
copious and frequent bloodletting. Some modern writers, likewise, recom- 
mended certain restrictions in this particular, but they have been content with 
general directions under this head. We shall not be able to effect much, unless 
precise directions as to the exact quantity and kind of food are laid down. Dr. 
Bellingham would limit the patient to three meals a day, the morning and 
evening meal to consist of two ounces of liquid, and the same of solid nutri- 
ment; the mid-day meal of from two to four ounces of liquid, with from two to 
four ounces of solid. The liquid may consist of milk or tea, the solid of bread; 
and at the mid-day meal, of bread and meat in equal quantity. No deviation 
from this dietary should be permitted, and it must be persevered in for a fixed 
period — six weeks or a month at least; when it may gradually be improved. 
If the patient is weighed on commencing it, and this done occasionally after- 
wards, we'-shall have a guide as to the advisability of continuing it, or of im- 
proving it. 

This plan of treating aortal aneurism is not proposed on purely theoretical 
grounds. It is applicable not only to aneurism of the thoracic and abdominal 
aorta, but to all those cases where the sac springs from a branch of this vessel, 
and is beyond the reach of surgical interference ; as to aneurism of the inno- 
minata, of the subclavian, and of the carotid at the root of the neck, as well 
as to aneurism of the common iliac. Dr. Bellingham has employed it, but for a 
shorter period, with much advantage, as a preliminary to the application of 
compression in popliteal aneurism. 



236 



Progress of the Medical Sciences. 



In a mode of treatment such as this, success will of course depend in a great 
measure upon the perseverance with which it is carried out. It is, therefore, 
necessary that the patient should be made aware of the dangerous nature of his 
disease ; as he will be more likely to submit cheerfully to the restriction. 
Indeed, unless he co-operates in carrying out the treatment fully and fairly, it 
can never be effectually maintained. 

It might be objected that the tendency of so very restricted a diet is to pro- 
duce a state of anaemia; but this result is scarcely to be feared, unless blood- 
letting is employed. 

Dr. Bellingham relates a case in which this treatment was carried out with 
great success. We subjoin the state of the patient at the commencement, and 
at the end of the treatment. 

Case. P. D., aged 50, admitted April 19, 1849. He now suffers principally 
from pain and cough : the pain commences at a point at the upper part of the 
right side of the chest, near the sternum, where a pulsation is visible; it darts 
through the chest to the scapula on the same side, and extends also to the axilla 
and right arm, sometimes reaching to the fingers, generally not extending 
below the elbow. He describes this pain as being most severe at night. He 
complains of pain on pressure over the site of the aneurism ; he cannot bear 
percussion there, and the application of the stethoscope even causes pain ; this 
is likewise much increased by coughing, but particularly by sneezing. 

For the last three weeks, he has been unable to lie upon the left side ; can 
lie upon the right, but he prefers lying upon the back. 

On examination, a pulsation is felt, and seen to the right of the sternum, 
above and below the junction of the cartilage of the third rib with this bone ; 
no tumour is prominent upon the surface, but the pulsation is well marked. 
This part is very painful to the touch, and to it particularly .the patient refers 
the pain which he suffers on coughing. On placing the hand on it, the pulsa- 
tion is felt to be double ; on placing one hand upon the sternum and the other 
upon the right scapula behind, a heaving of the chest is perceived with each 
ventricular systole. 

On auscultation over the aneurism, a loud double sound is audible, which is 
synchronous with the double impulse, and resembles accurately the double 
sound of the heart ; it diminishes in intensity as we approach the heart ; no 
murmur accompanies either aneurismal sound. The heart's action is strong, 
and felt over a large surface ; the impulse of the apex is lower down than natu- 
ral, towards the epigastrium ; its sounds normal. The pulse 80, regular, having 
the same strength in both wrists ; the inspiration is bronchial over the site of 
the aneurism ; the expiration not altered. 

June 28. The patient has been up now for some days ; he feels weak, but 
makes no complaint of pain or uneasiness ; the pulse is 80, and small in the 
sitting posture ; the carotids are observed, and felt to pulsate strongly ; slight 
jugular pulsation is observed above the clavicles ; no pulsation is visible to 
the eye at the site of the aneurism, but a slight movement is perceptible in that 
part of the chest when the hand or stethoscope is laid on it, but is unlike that 
of an aneurism. On auscultation, the double sound is well marked over the 
seat of the aneurism ; no bruit accompanies the first sound, but a slight bruit 
is audible at one point with the second sound. 

He was soon discharged from the hospital ; and, when seen by Dr. Bellingham 
recently, he had continued in a satisfactory state, and had been able to follow 
his employment as a shoemaker from the time of his dismissal. 

The following are the Conclusions with which Dr. Bellingham sums up his 
paper: — 

1st. Aneurism of the aorta is not necessarily an incurable disease. 
2dly. It appears to be more amenable to curative treatment than is ordi- 
narily supposed. 

3dly. Treatment ought always to be especially directed to this object. 

4thly. When a spontaneous cure occurs, it is always by the gradual depo- 
sition of the fibrin of the blood in layers within the aneurismal sac until it is 
filled up. 

5thly. If we hope to succeed in effecting a cure, it must be by imitating the 
mode in which Nature brings this about. 



1852.] 



Surgery. 



237 



6thly. In order to favour the gradual deposition of fibrin, we should aim at 
diminishing the mass of blood, and lessening the strength and rapidity of the 
current through the aneurismal sac. 

7thly. This can only be indirectly accomplished by acting upon the general 
circulation. 

8thly. Neither bleeding, purgatives, diuretics, digitalis, nor the various other 
remedies which have been employed in this disease, can be depended upon for 
producing these effects. 

9thly. An extremely restricted diet, particularly in fluids, continued for a 
certain time, appears to have the effect of rendering the pulse small, compress- 
ible, and slow, and at the same time diminishing the mass of blood. 

lOthly. The cases related afford evidence that these results may be brought 
about by treatment conducted upon the foregoing plan. 

llthly. This method of treatment, to prove effectual, must be steadily and 
perseveringly carried out, and must be continued until a decided impression is 
made upon the disease. 

12thiy. It is adapted not only to aneurism of the thoracic and abdominal 
aorta, but to aneurism in any of the immediate branches of these vessels. And 
if employed as a preliminary to compression, pain will be diminished, and the 
duration of the treatment considerably abridged. — London Journ. Med., May, 
1852. 

23. Popliteal Aneurism cured by Compression. — T. Stephens, Esq., commu- 
nicated to the Newcastle Pathological Society the following case : A fisherman, 
aged 50, came under his care in September last, with a popliteal aneurism. 
The tumour at that time was the size of a pullet's egg cut in two, felt hard to 
the touch, and pulsated strongly, which pulsation was easily stopped by pres- 
sure on the femoral artery. The patient being unwilling to undergo an ope- 
ration, Mr. T. determined to make a trial of compression. Two pads were fixed 
on the femoral artery by means of elastic ring tourniquets, but not so tight as to 
completely control the pulsation in the tumour. On the following day, the upper 
one was slackened, and the two were afterwards alternately tightened and 
loosened, for about twelve hours at a time. In about seven days, the foot and 
ankle became so tender and painful that he begged the apparatus should be 
taken off. Mr. T., however, continued it with a diminished pressure. On the 
eighth day, the pulsation had diminished, but not ceased. On the ninth day Mr. 
T. took off the apparatus, and re-applied it on the tenth. On the eleventh, it had 
somewhat increased ; on the twelfth, it was scarcely perceptible ; and, on the 
fifteenth, no pulsation was to be felt. The leg and foot became extremely cold 
and pale, but the heat was gradually restored by means of friction and flannel 
bandages. On visiting him about three weeks after, Mr. T. found the tumour 
nearly gone, and the patient has now resumed his employment. — Med. Times 
and Gaz., April 3, 1852. 

24. Account of the Dissection of a Subject in whom two Popliteal Aneurisms 
had been treated by Compression four years previously ; with some Remarks, and a 
Table of the Cases in which Compression has been successfully employed. — This is 
the title of an interesting article in the Dublin Medical Press (Dec. 3, 1851), by 
O'B. Bellingham, M. D. The subject of the cure was a man 34 years of age, 
who had been affected with popliteal aneurism in both limbs, which had been 
treated by compression. The patient's death was the result of aortal aneurism. 
We have not space to give the details of the case, but the more important points 
are furnished in the following observations which are appended : — • 

These pathological specimens illustrate in the one limb the mode in which 
compression effects the cure of aneurism, and in the other, the subsequent 
changes which ensue by which the recurrence of aneurism, at the same part of 
the artery, is effectually prevented. 

This patient lived above four years after the treatment of the two aneurisms 
in opposite limbs ; upon the side that the aneurism had been cured, and where, 
after the cure, a solid hard tumour, of the size and shape of a racket-ball, 
marked the site of the aneurismal sac, we now find no remains of an aneuris- 
No. XLVIL— July, 1852. 16 



238 



Progress of the Medical Sciences. 



[July, 



mal sac ; the sac and the artery at the part are consolidated into one, and merely 
a solid rounded ligamentous cord marks the site of the aneurism and of the 
part of the obliterated popliteal artery from which it sprung. 

In the opposite limb, where the compression was kept up for a much shorter 
period, and where the aneurism did not cease to pulsate, we find the aneurismal 
sac greatly diminished in size, its walls very thick, its interior tiearly filled 
by fibrin, and the artery at the part not obliterated, but permitting a cur- 
rent of blood still to pass through it. 

On previous occasions, I have had the opportunity of exhibiting to the mem- 
bers of the Society preparations illustrating the results of compression for the 
cure of aneurism from subjects who died of other diseases, either subsequent 
to the cure of the aneurism or before the pulsation had ceased. The present 
differs from any hitherto recorded, and is, perhaps, more important, as it bears 
upon a point which we had not the opportunity of determining heretofore, 
while it tends, as much as any single case can, to confirm all that has been said 
of the advantages of this method of treating aneurism. 

In the details of this case, I have said that, after compression had been em- 
ployed for a time upon the right lower extremity, it was discontinued before 
the pulsation of the aneurism had ceased, in consequence of the patient being 
obliged to return to his employment. Notwithstanding that the pulsation con- 
tinued, the tumour not only did not increase subsequently, but actually 
diminished in size, although the patient had to work at a very laborious em- 
ployment, in which he was obliged to lift and carry heavy weights; and during 
upwards of four years that intervened between the period at which the pres- 
sure was discontinued and the patient's death, it never caused the slightest 
-inconvenience, and he continued to work until the enlargement of the thoracic 
aneurism compelled him to desist. 

The post-mortem examination shows why this was so : we find the aneu- 
rismal sac contracted and diminished in size, its parietes much thickened, and 
its cavity in great part filled up by fibrin deposited in concentric layers. A 
small portion of its interior still permitted the entrance of the blood, which 
passed down the popliteal artery, the pulsation of which communicated to the 
sac gave the impulse which was felt at the part during the patient's life. 

It is a point of some interest to determine whether an external aneurism can 
be considered to be cured, although the channel of the artery, at the seat of the 
disease, is not obliterated, and a current of blood continues to pass through the 
vessel. We know that when aneurism of the arch of the aorta undergoes a sponta- 
neous cure, the sac alone is filled up, while the artery, for an obvious reason, con- 
tinues pervious afterwards. Now, the examination of this preparation, combined 
with the history of the case, affords evidence that popliteal aneurism may be so far 
cured that the sac can scarcely enlarge again, although there is no obliteration 
of the artery at the seat of the disease, and likewise that this desirable result 
may be brought about by making compression upon the artery on the cardiac 
side of the sac. 

The cause of the enlargement of an aneurismal sac, in any situation, is evi- 
dently the distension from within, caused by the impulse communicated to the 
blood by the systole of the left ventricle. If this distension can be diminished, 
or prevented altogether, the aneurismal sac cannot enlarge ; but it will, on the 
other hand, rather diminish in size. Now, by making pressure upon the artery 
leading to an aneurismal sac, we can take off this distension, and render the sac 
quite flaccid, and by continuing the compression we can maintain the sac in this 
state for an indefinite length of time. Moreover, when the current of blood 
through the sac is materially diminished in force, velocity, and volume, another 
agent almost always comes into operation ; the fibrin of the blood, in its pas- 
sage through the sac, is deposited upon its interior, by which the parietes of the 
sac are still further strengthened. 

It would appear, indeed, from the results of one or two cases, where the dis- 
ease was of very recent origin, that, when compression upon the artery above is 
steadily maintained, the aneurismal sac may gradually shrink until reduced to 
a very small size ; and if the precaution is taken of not allowing a full current 
of blood to pass down the artery for a certain period, the remains of the 



1852.] 



Surgery. 



239 



shrunken aneurismal sac ultimately are scarcely to be felt, particularly if its 
site was the popliteal space, or Hunter's canal, where the vessel lies at some 
distance from the surface. 

It can scarcely, then, I think, be doubted that aneurism, in an extremity, may 
be so far cured that it can neither enlarge again nor give way, although the 
blood continues to pass through the artery from which it springs, and an im- 
pulse continues to be felt at the part, owing to the pulsation of the artery being 
communicated to the sac. In the present case, there was an interval of above 
four years between the discontinuance of compression and the death of the 
patient; during which time, although the pulsation continued, the patient was 
able to follow a laborious employment, and never suffered the slightest incon- 
venience from the aneurism. Indeed it is not improbable that the femoral 
artery has been unnecessarily tied in some cases, at least under similar circum- 
stances, where, if a little delay had been permitted, it would have been found 
that the aneurism had no disposition to increase in size. 

The preparation from the opposite limb of this patient, in which the aneurism 
had been cured, is also of some interest, as being an additional example of the 
subsequent changes which ensue after the cure by compression, by which Nature 
effectually prevents the recurrence of aneurism at the same part of the vessel ; 
as well as because it shows, in some degree, within what period these changes 
are brought about. The treatment of the aneurism in this limb was, as I have 
remarked, rather tedious, extending over a period of three months ; after the 
cure, the site of the aneurismal sac was marked by a very solid, hard tumour, 
resembling a racket-ball in shape and feel — a proof that the sac was filled with 
solid fibrin. About three years subsequently, upon a careful examination of 
the limb, no trace of this tumour remained ; and now, after four years, we find 
that the aneurismal sac, and the fibrin with which it was filled, have been en- 
tirely absorbed, and merely a solid ligamentous cord marks the site of the 
obliterated popliteal artery and aneurismal sac. 

The last point illustrated by this preparation, to which I wish to call attention, 
is the condition of the femoral vein. It will be seen that this vein, throughout 
its whole course in the thigh, as well at the points at which the compression 
had been made, as at those where no pressure had been applied, preserves its 
natural healthy appearance ; its valves are sound, there is no thickening of its 
coats, and no alteration of any kind is perceptible either upqn its exterior or 
in its interior. Now, the treatment of the aneurism in this limb extended, as 
I have said, over a period of about three months — viz., from the middle of Oc- 
tober to the middle of January; and during much of that time the pressure 
was made upon the middle and lower third of the thigh, where the artery and 
vein are very closely united, and the latter was of course necessarily com- 
pressed with the former. 

It has been gravely proposed that, in using pressure for the cure of aneurism, 
the pad of the compressing instrument should be so applied as to avoid making 
pressure on the femoral vein ; any one, however, who has dissected the parts, 
must know that this would be utterly impracticable ; and every one who has 
tied the femoral artery knows that one of the chief difficulties in the operation 
consists in avoiding injury to the vein, in consequence of its close proximity to 
the artery ; indeed, Mr. Porter has shown that, in cases of popliteal aneurism, 
" The femoral vein is always more closely adherent to the artery than in the 
healthy subject;" and this is evidently the case in the preparation before us. 

I have myself had the opportunity of examining the condition of the femoral 
vein after the cure of popliteal or femoral aneurism by compression, in several 
instances in addition to the present ; and in none did this vein present the slight- 
est change, proving that it bears pressure equally as well as the artery, and that 
if the treatment is properly conducted, neither vessel can suffer any injury 
from the compressing instruments. 

' Dr. B. gives the following list of cases, which have been published, of aneu- 
risms healed by compression : — 



240 



Progress of the Medical Sciences. 



.3 1 



o £ 

lis 



:1: 
~ 3 £ 

<D X S- 



3 5 
o n 

,0 3 



© 3 



o a 



Si 



© o 
S © 

2 3 



a 5 
~3 

os a 



II 

o 



|i| 

<~,3 d 

g § a™ 

H pM a 

•1 a 



3 f 



; 1 1 
; § l* i 

i = a a 
i * 8 g 



is 



t _ 



§ 1 



m 



3-3 



— O © £ 



o q 



|g s 



t) S s 

£££ 



P ,2 p ,C ,C ,Q 

a S a s = =s 



"3 o 



£ 'S 
a£ o 

prj O m 

flO,g 
^ %> 
a © . 



Sa 

h gal* 

9 ° if -2 o « S "3 

| l^s CI 

1-5 E <? s; S Hai^ 



| 1H1 1 

SI as 111 I 



© 23 *a "** u 

C oq S <! -x < <i 



£££ 

PV A 



© — 

IS 
1 1 

S -t> 
1-5 71 



3 



B 

a 

&3 3 : 



HIP 



£JJg€f3 
kSkb p; n 



© o © 

a 
m 



t- r- s x c-i yi ocKrj^N'f^ o 



/3 

= 1 n 



ex a 

O ^ © ^ fl 



1 £2^ S^-S 



11 

pqpq 



m o i- cc c. © 



1852.] 



Surgery. 



241 



r2 U 



A 53 

^.2 
a a 



§1 

OA 

.23 a 



<H -d 



a o o 
o 



O O 



1^1 



^ a 1-5 

PI* 

*3Sp* 



^ o 



O «R O O M O o 

t3 aa^ ^ o 

a o i> s 



>> o 

HP 



§6 

g § g 'I a | 



t- r-l OO 














<N CO 










"3 6 6 


d 


d d 6 d 6 6 6 


d d 




t3 


13 ^5 n3 'ZS rS IS ^ 





o a 
PS § I 



an 



6 



6 



Si? 

rd « 
d 

2 '-3 



a> o 
■+5 

5d ft 



rS ^2 

§■8 

^ « 
3 a. 
O m 

31 

.d-3 

^ to 
~ c3 

"3 

•2-d 

-+J o 



.2 

I 

'5 a" 

« 

2 « 

"3 ft 

II 



-§1 

2 s 
a « 

ts a 
3^ 



1 a f " 

£ a-J3 



1 d d 





1^ 

S ■§ 

p p 



81 

o3 a 
hip 



a y 
c3 a 

HP 



3 OT 



• «1 

o 

P s 



3 3 * fi 

a ft 



r-S «s 

ra <u -*2 



is "So 



IS J 



c3 ""Si? O e3 o 
TJ1 Ofi 02 P^CO 



S §> J g 1 J -2 

? J s£ 3 "C l2 3 

OOOIOHNM"* 
rH rH rH iH tH 



242 



Progress of the Medical Sciences. 



a a 

© o 

a a 



a a a 

poo 

a aa 



s a a 

H H Eh 



8Z g'g 

alls 

.2 g a .S 

a 



I 11 

GO Ph pq 



s if 



JS 



a s a a 
■S g -I *s 

© o o © 

C'-S a 3 

cS e3 s3 o3 

.2 a .2 .° 

Ull 

Sh O Sh 



p o o o 

p -3 ^3 ^ 
O 



-3 £ 
£ « £.2 

2 2 Eg o 

^ a • 
.2 ^ M -a 

a^|§ 

3 s © d 
aS § 2 



a • a . 

m O bCO 



*3 



1852.] 



Surgery. 



243 



It will be seen that the foregoing table includes fifty-four cases of popliteal 
and femoral aneurism — viz., forty of popliteal, and fourteen of femoral; three 
cases of brachial aneurism; four of radial or ulnar aneurism; and one of 
aneurism of the anterior tibial artery. I have not admitted any case into this 
list where the patient was not cured, and did not live for some years afterwards. 
I am aware that it does not include every case which has occurred during the 
period in question, as some have not been published, and perhaps a few others 
have escaped my notice, or have appeared in journals to which I had not 
access. 

25. Deligation of the External Iliac Artery. —John Harris, Esq., senior sur- 
geon to the Devon and Exeter Hospital, on the 25th of October, 1851, applied a 
ligature to the external artery, in a man 29 years of age, for an aneurism of the 
femoral artery, on the left side, immediately below Poupart's ligament. The 
patient was in robust health ; the tumor had existed only a month, and was 
about the size of a turkey's egg. The ligature came away on the 19th day, and 
the patient was discharged cured on the 11th March. 

This is the sixth time that the operation has been performed in the Devon 
and Exeter Hospital within the last twenty-five years, and five out of the six 
successfully. In the unsuccessful case, the patient died from consequent peri- 
toneal inflammation. 

26. Operations for Retention of Urine, occasioned b y inveterate Stricture. — [John 
Simon, Esq., in a clinical lecture, delivered at St. Thomas's Hospital, made 
some remarks on this subject, and gave an account of a method of operating 
which is worthy of consideration.] 

When your patient, by reason of a stricture in the urethra, is unable to 
empty his bladder along the natural channel, and when you are foiled in your 
utmost endeavours to effect this for him by catheterism, or by the employment 
of other appropriate means, in that emergency, when it arises, how are you to 
give an artificial vent to the urine? 

I purpose illustrating to you, in the present lecture, what I consider the 
right answer to this question. I shall explain to you the general principles 
which determine the surgeon to make artificial openings into the urinary pas- 
sages; and I shall give you the rationale of a line of treatment, which you have 
seen me adopt successfully in various cases, as a substitute for the operations 
more commonly practised. 

First, however, let me impress on you that, in the hands of a skilful surgeon, 
the emergency to which I advert is not a frequent one, and that you must not 
too readily admit its existence as your ground for the operations in question. 
I cannot now go into the whole subject of inveterate stricture ; but, if you have 
given attention to the routine of hospital practice during a few months, you 
must know that, in an immense majority of instances, even of very old, very 
tight, very obstinate stricture (provided other conditions are absent to which I 
shall presently refer), we succeed in giving relief, without recurring to the last 
expedient of knives or trocars. 

The necessity for making an artificial opening into the urinary passages may 
be established, for such cases as we are considering, under any one of these 
three conditions, viz. : — 

(1) All means for procuring the natural discharge of urine may absolutely 
fail; (2) urgent constitutional distress may render it dangerous to temporize, 
as in attempting the gradual dilatation of the stricture; (3) the urethra may 
have ulcerated at the seat of stricture, and may be allowing extravasation of 
urine to occur, with its attendant wide- spread mischief. 

1. As regards the first condition, I believe it to be of the very utmost rarity. 
Taken simply and singly, it has never yet driven me to the necessity of operat- 
ing. The local state of stricture which determines complete retention of urine 
is a compound one. Though the canal be permanently so small as to make 
urination very laborious, perhaps allowing the patient to effect it only guttatim ; 
yet that which brings him to a dead lock is a temporary work. The mucous 
membrane is swollen by some additional congestion of blood, or the canal is 



244 



Progress of the Medico! Sciences. 



[July, 



obliterated by muscular spasm. And over this temporary aggravation we have 
great control. A full dose of opium, aided, perhaps, by leeches to the peri- 
neum and by the hot bath, or in some cases preceded by the action of a brisk 
purgative, Trill generally give relief ; and thus, even if we cannot extempora- 
neously get a catheter into the bladder, we can re-establish the patient in his 
previous state of dribbling urination ; we can insure that his bladder shall 
partially evacuate its contents; and we can gain time for that gradual dilata- 
tion of the stricture which will bring more complete and permanent advantage. 
With these resources in your hands, and with an expert, but, above all, a gen- 
tle and patient management of the catheter, I can promise that you will scarcely 
ever find yourselves defeated in uncomplicated cases of retention of urine from 
stricture. Should that rare contingency arise ; should your milder measures 
utterly fail; should the urethra remain absolutely impervious, letting in no 
catheter, letting out no urine ; then, undoubtedly, as I have stated, this condi- 
tion would establish a necessity — a legitimate, an imperative, and urgent ne- 
cessity — for your making an artificial vent for the distended bladder. 

2. The second specified condition for the performance of such an operation 
is a more frequent motive than the first. The stricture, though very close, may 
not be quite impervious ; it may let enough urine pass to keep the bladder free 
from fatal distension ; it may even (though this would be unusual) permit your 
smallest catheter to traverse it ; yet, with all this, your patient may be dying. 
He is an old man, perhaps, with a shattered constitution ; he has been plagued 
with his stricture for years ; it has been neglected or aggravated ; his urine is 
fetid and full of pus ; he has had constantly recurring rigors ; his loins are 
painful and tender : every attempt at dilatation of his urethra gives severe 
suffering; his shiverings and sweatings have left him each day feebler; his 
weak pulse beats above 100 in the minute ; his hands are tremulous ; his tongue 
is getting dry; he is threatening to become typhoid, breaking down under the 
prolonged irritation of his local disease. You may entertain no doubt that, 
with time, you could dilate his stricture ; but here exactly it is, that time is an 
ally you cannot reckon on. A fortnight or three weeks would be requisite for 
your endeavour to have any success ; and far within that period you would 
have nothing but the dead body to catheterize. Here, obviously, there is urgent 
need for immediate and complete relief, for relief that shall at once put the man 
into a tranquil and painless state; and the establishment of an artificial outlet 
for his urine is the clear indication of treatment. 

3. The third condition which I have stated to warrant the necessity of this 
proceeding, is that under which we most commonly adopt it — where, namely, 
the urethra has given way behind the seat of stricture, and presents an aper- 
ture through which, at every contraction of the bladder, urine is effused amid 
the adjacent textures, exciting them to inflammation and gangrene. I need 
hardly tell you, that cases of this description are among the most urgent in 
surgical practice, and that the utmost promptitude of relief is requisite for the 
patient's safety. Though the stricture, so far as that goes, may be of a kind 
likely to yield to gradual dilatation, yet, pending this slow process, what is to 
become of the urine? Is it to continue its destructive course of effusion amid 
living textures? Manifestly not; and therefore the local treatment resolves 
itself under two heads ; first, to adopt such a course, relatively to the strictured 
and perforated canal, as will prevent any further extravasation of urine ; se- 
condly, to make such incisions as may be requisite for discharging out of the 
infiltrated tissues all their fetid accumulation of urine, pus, and sloughs. In 
seeking to fulfil the former of these indications, we find it necessary (as under 
the conditions previously considered) to make an artificial passage for the urine ; 
and the operation, as I have said, has its most frequent necessity in the condi- 
tion here adverted to. Out of six cases, which I shall presently bring before 
you, in which I was obliged to perform the operation in question, five were 
cases in which the urethra had given way, and extravasation of urine was in 
progress. 

And now, gentlemen, suppose the necessity to be established for your giving 
an artificial passage to the urine ; suppose one of the three conditions to be 
present which I have stated to you ; that you cannot procure any discharge 



1852.] 



Surgery. 



245 



whatever by the natural channel : or that your patient is suffering urgent con- 
stitutional distress from the insufficiency of such relief as you have procured 
him : or that the perineum and genitals are beginning to swell with extrava- 
sation of urine ; now, what course have you to adopt ? 

The operation which for a great many years has been prevalent here ('and. 
indeed, in most London schools of surgery) has been the following: (1) A ca- 
theter or sound has been passed up to the seat of stricture, at or near the bulb 
of the urethra ; (2) a long cut has then been made in the raphe of the perineum, 
reaching down to the urethra, and opening it behind the seat of stricture : 
(3) the urethral incision has been prolonged forwards, towards the point of the 
catheter or sound, so as to split open the contracted portion of the canal ; and 
finally (4) all impediments being overcome, a large catheter has been conducted 
along the urethra into the bladder, and there secured by appropriate bandages. 

You will find this operation fully described in Mr. South's translation of 
Chelius, and spoken of as the practice of the borough hospitals for the past 
thirty or forty years. And, if you wish to see the operation in its most favour- 
able aspect, you cannot do better than observe it in Mr. South's hands, who has 
had great experience in the proceeding, and who executes it with all the care 
and patience which are indispensable for its success. 

Professor Syme, of Edinburgh, who is a great authority in such matters, 
speaks of this operation as " protracted, uncertain, dangerous, and unsatisfac- 
tory." Looking to its average performance, I must say my experience would 
justify this censure. It is protracted, for the patient undergoes severe manipu- 
lation during a period of which the mean would be twenty to thirty minutes. 
It is uncertain, for the division of a stricture or strictures to which one is Bo 
imperfectly guided cannot be accomplished with facility : nor can one feel sure, 
under the most favourable circumstances, that one's scalpel has hit the exact 
line of a canal contracted ' perhaps for an inch of its length ) to such narrow 
dimensions as scarcely, if at all, to admit the smallest catheter.* It is dan- 
gerous, because (in addition to the sources of risk just adverted to) large hemor- 
rhage not unfrequently contributes to exhaust the patient : and further, because 
in many cases (as where the urethra is contracted throughout its whole spongy 
portion") a catheter cannot be maintained in the passage, without prolonging 
that state of pain and irritation which already have set life in jeopardy. And 
unsatisfactory it must be on all these grounds. For what can be more so than 
to conclude a severe and dangerous operation with uncertainty as to whether 
one has accomplished that very object for which the severity and the danger 
were encountered? 

These objections apply to the proceeding as practised by the best (I mean the 
most careful) operators. In other than good hands, it is a very horrid affair : 
metallic instruments are thrust in all directions ; they leave the canal at one 
place, and re-enter it by perforation at another ; or they pas3 up to the hilt — 
one shudders to think where ! — and draw no water ; the rectum, the prostate, 
even the bladder, undergo injury in these violent efforts, and the patient is 
eventually sent to bed, it may be with his bladder unemptied, having his chance 
of cure sensibly diminished by the infliction of so much unnecessary mischief. 

We cannot be surprised that many surgeons have taken refuge from the pre- 
carious chances of this operation, in the comparatively simple and secure pro- 
cess of tapping the bladder by the rectum or above the pubes. I shall presently 
describe to you the operation which, generally speaking, I consider a far pre- 
ferable alternative even to these. But. before examining their comparative 
merits, I have still something more to say in respect of the last. 

Within these few years, Professor Syme has introduced a method of dealing 
with obstinate strictures, by dividing them on a director previously passed 
through the constriction : and you may ask whether the adoption of this ma- 
noeuvre would be applicable to the cases we are considering, so as to remove 

* ■ Even under the most favourable circumstances, it cannot be otherwise than doubt- 
ful whether the stricture be properly divided; that is, whether the incision has passed 
through the narrow canal in the centre, or through the solid substance on one side. v — 
Brodu on Diseases of Urinary Organs, p. 65. 



246 



Progress of the Medical Sciences. 



the objections I have expressed to the operation of dividing the stricture -without 
any such assistance ? I think not. The cases heretofore treated by Mr. Syme's 
operation have not been cases where the primary consideration is to give imme- 
diate relief to a distended bladder, or to provide against advancing extravasa- 
tion of urine ; and in cases such as these there are generally circumstances 
which would render the director inadmissible. If the urethra is impervious to 
a small catheter, it is not likely to yield to this other instrument ; if the canal 
has ulcerated, so as to communicate with infiltrated and sloughing tissues, or 
is riddled with false passages, the director would be not unlikely to prove a 
treacherous guide. Here and there one might find a case in which (supposing 
division of the stricture to be our desideratum) Mr. Syme's principle would 
admit of application ; but, speaking generally, I may repeat that his proceeding 
relates to quite a different class of cases. 

But, gentlemen, if that " protracted, uncertain, dangerous, and unsatisfac- 
tory" operation, which I have described, could admit of serviceable modification 
by Mr. Syme's proceedings, there is yet another reason, I think, which would 
induce us to reject it. 

The operation held its ground because of its alleged completeness. The no- 
tion of dividing (and therein curing) the stricture, at the same moment as one 
gave relief to the distended bladder, was indeed charming. But, of late years, 
surgeons have discovered, that this seductive completeness had in it a practical 
fallacy. The division of the stricture was the sheerest superfluity. Let the 
bladder be relieved any how — by the perineum, by the rectum, by the pubes ; 
merely let the stricture for awhile be undisturbed by the constant irritation of 
urine urged against it from behind, and there speedily occurs a spontaneous 
perviability of the canal. The stricture wants no cutting. It loosens itself. 

So remarkably does this effect belong to the withdrawal of pressure from the 
stricture, that it arises, not only when the surgeon has made an artificial outlet 
for the water, but also under far less favourable circumstances ; namely, where 
the urethra has given way behind the stricture, and where the bladder expends 
its chief expulsive force in driving the urine into surrounding textures. " The 
first effect of this mischief," says Sir Benjamin Brodie, " is to relieve the pa- 
tient's sufferings; there is no more straining, and the spasm of the stricture, no 
longer excited by the pressure behind, becomes relaxed, so as to allow some of 
the urine to flow by the natural channel." Further, in the very numerous 
cases where the endeavour to divide a stricture has been defeated by the diffi- 
culties I have adverted to, and where, contrary to the performer's intention, 
the operation has not advanced further than the stage of cutting into the blad- 
der or urethra somewhere behind the obstruction, the same loosening of the 
stricture has been observed to ensue, as though it had actually been divided.* 

Surely, it cannot be desirable to incur difficulties and dangers in attempting 
to divide a stricture, when the same advantages spontaneously arise without 
that division being accomplished. 

These considerations have led me to the modified perineal operation, which 
you have seen me perform in various instances, and which consists simply in 
this : I open the urethra by puncture, or by very small incision, immediately 
in front of the prostate gland. I run a short elastic catheter along this wound 
to the bladder. I leave the stricture quite untouched for ten days, more or 
less, during which the urine flows entirely by the perineal catheter. At the 
end of this time, I find the stricture sufficiently relaxed for me to begin its dila- 
tation with a middle-sized instrument; and I thus obtain all the advantages 
assigned to the severer and more difficult measure, while adopting an operation 
of extreme slightness and security. 

I have already intimated to you that many surgeons, feeling the risks and 
difficulties which are inseparable from the ordinary perineal operation, have 

* " In cases of stricture, if the stricture be so far forward that it be not involved in the 
wound in the perineum, or by sloughing, if urine be extravasated, it generally relaxes 
so much that it can be cured by the ordinary treatment with bougies or sounds, during 
the reparation of the wound in the perineum." — Mr. South, in note to Translation of 
Chelius, vol. ii. p. 436. 



1852.] 



Surgery. 



247 



chosen rather to tap the bladder, in such cases as we are considering, either 
above the pubes or by the rectum. Obviously, on the principles which I have 
stated to you, either of these proceedings might give very satisfactory results. 
The bladder would be effectually emptied, and the stricture relieved from irri- 
tation ; supposing the urethra to have given way, diffusion of urine would be 
prevented : and neither of these operations can be considered very difficult or 
very dangerous. 

If, therefore, my choice lay between the ordinary perineal operation and 
these other expedients, I should not hesitate to prefer one of the latter. But 
the modified perineal operation which 1 advocate is still simpler and safer. 

I admit, for instance, that tapping the bladder through the rectum is not a 
very difficult or very dangerous operation. A man of ordinary skill can hardly 
bungle it. Yet it is not quite so simple a matter as driving your trocar into a 
hydrocele. It requires some practice and dexterity. I have known an able 
surgeon, in attempting it, make two successive stabs; the first went by the side 
of the bladder, the second transfixed it. And I should doubt whether, even 
under the most skilful management, the peritoneum would always be so safe 
from injury as the advocates of the operation believe. 

But assuming, for argument's sake, that the manipulation shall never mis- 
carry by any such slips as these, I can still scarcely approve of the operation. 
To bore a hole through the rectum would seem, at first blush, a roundabout 
way of emptying the bladder. It strikes me as an awkward and unworkman- 
like proceeding, to involve a second viscus unnecessarily in the attempt to re- 
lieve a first. One would wish to minimize the injury of one's operation ; and, 
if one can relieve the bladder equally well without wounding the rectum — if 
one can accomplish one's purpose by a direct cut through the common integu- 
ments, or little more, surely one would argue prima facie that the rectum should 
be let alone. For the wounding of the bowel cannot be a matter of indifference. 
The track of the trocar between the seminal vesicles must be the seat of irrita- 
tion — not often, perhaps, to a serious extent, but certainly sometimes. Occa- 
sionally; no doubt, an abscess forms there, aided by a little infiltration of urine ; 
and from such a beginning as this very multiplied mischief might arise and 
continue. I understand there died in this hospital, not long ago, a patient who, 
at some previous time, had undergone elsewhere the operation in question; and 
in whom the irritation occasioned by it had never subsided. There had appa- 
rently been formed, in the manner just suggested, an abscess between the two 
openings ; urine continued to flow through the rectum, with extreme discomfort 
and tenesmus ; and the man's health was undermined by this continued suffer- 
ing and irritation. I repeat, therefore, that the rectal operation, as compared 
with the ordinary perineal section, presents unquestionable advantages ; but, 
as compared with the modified perineal operation, it must be considered, I 
think, to have the disadvantage of inflicting unnecessary injury, and incurring 
unnecessary risks. 

The supra-pubic tapping of the bladder is even easier of performance than 
the rectal operation, and has some other arguments in its favour. Indeed, 
there are cases, though not such as we are now considering, in which the blad- 
der cannot be relieved by any other proceeding. Such are the cases in which 
invincible retention of urine is occasioned by tumours of the prostate ; for here, 
obviously, no perineal incision would carry us beyond the obstruction, and the 
morbid growth would render tapping per rectum difficult or impossible. 

But, as respects cases in which our necessity to operate depends on stricture 
and its consequences, I cannot think the supra-pubic puncture a desirable pro- 
ceeding. The distance to which the contracted bladder retreats, so soon as its 
contents are discharged, is a matter of serious inconvenience. The areolar tis- 
sue between the bladder and the abdominal wall may easily get irritated by 
soakage of urine. The opposed edges of the recti would, in any such case, be 
an obstacle to the escape of the unhealthy accumulation. Further, notwith- 
standing the facility of the puncture, mischances have happened in its per- 
formance ; and, both in the operation and afterwards, the posterior wall of the 
bladder has suffered from the trocar or the canula. 

Reviewing the objections I have briefly stated, I cannot but give a decided 



248 



Progress of the Medical Sciences. 



preference to the modified perineal operation, in all cases which admit its ex- 
ecution. The point of the urethra selected for the puncture is definite in its 
position. It is readily reached from the surface of the perineum. No import- 
ant parts intervene. The subsequent escape of urine is direct. The position 
of the catheter causes little inconvenience. The perineal incision necessary 
for reaching the urethra is in nearly all cases required by accumulations of 
pus and extravasated urine. In such cases nothing is wanting to relieve the 
bladder but to deepen this incision into the urethra itself — a proceeding surely 
both milder and more obvious than if, after cutting deeply into the perineum 
for pus and extravasated urine, one were to start de novo with a trocar, to tap 
the bladder by the rectum or above the pubes. 

[Mr. Simon then gives the history of six cases in which he performed the 
above operation, and concludes his lecture with the following remarks on the 
mechanism of the operation.] 

I need scarcely add to what I have already said, beyond recommending you 
to practice on the dead body, at every convenient opportunity, the art of reach- 
ing the urethra at its membranous portion without the guidance of a staff. On 
your power of doing this depends your right to attempt the operation I have 
described to you. But what can be easier ? The canal which you wish to 
penetrate is not a small one ; often, indeed, it is considerably dilated in conse- 
quence of the diseased condition which obliges you to operate ; its position is 
invariable, and in every point of its course can be readily explored from the 
surface. The bulb is subcutaneous. The prostate you feel within the anus. 
The length of canal between these two points is not an inch ; its course straight 
in the median plane. Any difficulty which might be occasioned by the bulging 
of the perineum with pus or extravasated urine ceases, of course, with your 
first incision, which (in such cases made with proper freedom) gives immediate 
vent to the confined fluid, and enables you to proceed with facility. Often in 
thin subjects, and where the urethra has not given way, the distension of this 
canal, as the patient strains to make water, will render it so evident, that your 
operation may resolve itself into a mere puncture with a lancet. In the less 
easy cases, where your subject is fat, or the perineum deep and infiltrated, 
there is really nothing to deserve the name of difficulty. You make a sufficient 
cut in the raphe, terminating a little in front of the anus, and sinking as deep 
as may be requisite into the cellular tissue. You may then, in the following 
way, arrive at the point of the urethra which you wish to penetrate. Pass 
your right forefinger into the anus ; ascertain, through the wall of the bowel, 
the position of the prostate ; bring your finger forward till it discovers the ante- 
rior extremity or apex of the gland; let it just pass this spot, and rest (nail 
upwards) pressing with its point immediately in front of the gland. Of course, 
if the parts were transparent, you would now see your finger indenting the 
membranous portion of the urethra at that hindermost point of its course 
where you purpose to puncture it. Now pass your left forefinger (nail up- 
wards) into the wound; advance it till (with the guidance of the finger in the 
rectum) it falls against the apex of the prostate ; there you so arrange it that 
the middle phalanx presses back the rectum ; the last phalanx lies along the 
prostate, with the tip of its nail indicating the spot at which the urethra 
emerges. Finally, withdrawing your right forefinger from the anus, and re- 
suming the bistoury, you run this along the left forefinger, till you penetrate 
the canal on which it rests, and immediately follow it by the short elastic 
catheter which you intend leaving in the bladder. 

The cutis made into the urethra, you observe, just at the confines of its 
prostatic and membranous portions ; a spot which is posterior to the seat of 
stricture, and is easy to hit, from the definiteness and invariability of its 
position. 

With a little practice on the dead subject, you will readily acquire the knack 
of doing this operation in the natural condition of the parts with a single punc- 
ture ; and you will find that disease alters those natural relations far less than 
is commonly stated. But in the most difficult cases which can come before 
you, if you follow the rule I have given you, and carefully determine through 
the rectum the exact point at which the urethra emerges, you will fail to find 



1852.] 



Surgery. 



249 



any embarrassment, and will complete the operation in much less time than I 
have taken to describe it. 

The after-treatment of these cases, for some days succeeding the operation, 
is not unimportant. Liberal allowance of stimulants is often required, some- 
times from the very first. This purpose I generally effect by wine, or (if the 
stomach be irritable) by brandy with soda water. Actual drugs I rarely use, 
unless it be to procure action from the bowels, which, if their secretions be 
much disordered, I do as early as possible, with either colocynth or compound 
rhubarb pill, in combination with blue pill. Opium I do not find admissible. 

As regards the history of the operation which I have recommended to you, I 
cannot give you very full details. If you refer to Sir Astley Cooper's Lectures 
on Surgery* you will find that, at the time of their delivery, he recommended, 
in cases of simple stricture, that a puncture should be made into the urethra, 
where distended by urine, immediately behind the seat of stricture; and Sir 
Benjamin Brodie (who rather leans to the rectal operation) speaksf of the 
puncture of the urethra as "a sufficiently simple and unobjectionable proceed- 
ing/' As far as I can judge from Sir Astley Cooper's scanty description, it 
was only in cases of stricture far forward in the urethra that he adopted this 
course, and "passed a lancet" into some part of the canal anterior to the bulb. 
At least, if he ever practised any such operation as I advise for strictures 
situated further back in the urethra, so that his puncture would have been 
made in the vicinity of the prostate, I suspect that he soon afterwards aban- 
doned it for the supposed advantages of dividing the stricture. The latter 
operation seems to have taken its rise about forty years ago. It was first prac- 
tised, I believe, by the late Mr. Grainger, of Birmingham (father of my dis- 
tinguished colleague, our teacher of physiology),, and is very well described in 
a volume of " Medical and Surgical Remarks," published by that gentleman in 
1815. It soon became the general operation for cases of stricture, and has been 
extensively practised, in the borough hospitals and elsewhere, down to the 
present time. When Mr. Grainger found himself unable to accomplish it, he 
used to make a partial division of the prostate, as in the lateral operation of 
lithotomy, and thus convey an elastic catheter to the bladder. 

Sir Benjamin Brodie recommends, in cases where the urethra has given way 
behind a stricture, and where a bougie can be introduced, that this should be 
used as a director for the introduction of a perineal catheter, and that the latter 
should be left in the wound for one or two days. 

I am not aware of any surgeon having habitually practised the operation in 
the form I have described ; and, from such observations as I have made on the 
subject, it seems to me well worthy of more general adoption. Practised in 
the manner I advise, it may, I think, entirely supersede the operations for tap- 
ping the bladder, except in those very rare cases of prostatic tumour where 
the supra-pubic puncture is inevitable. It likewise entirely annuls the sup- 
posed necessity, while it avoids the difficulties and dangers, of dividing the 
stricture in perineo for the relief of retention of urine. And its advantages, 
meanwhile, are purchased by so trifling an endurance of pain, inconvenience, 
or injury, that I could not cite to you, from the whole practice of surgery, any 
parallel instance of disproportion between means and results — any instance 
where, from an extremity of disease, suffering, and danger, the patient is sud- 
denly removed, by surgical appliances so simple and so secure, to a condition 
of comparative enjoyment and safety. 

The only argument likely to be urged against the proceeding in question is 
one which I may best anticipate and answer in Sir Astley Cooper's words : 
"This operation has been objected to (he says) on the supposition that it re- 
quires great anatomical knowledge. To this objection, I will say, that he who 
is adverse to an operation because it requires anatomical knowledge, should 
immediately give up his profession ; for if surgery be not founded upon an 
accurate knowledge of anatomy, it will be better for mankind that there should 
be no surgery, as disease will proceed better with the natural means of relief 
than with the aid of those surgeons who are not anatomists. — Med. Times and 
Gaz., April 10 and 17, 1852. 



* Vol. ii. pp. 315—317. 



f Diseases of Urinary Organs, p. 42. 



250 



Progress of the Medical Sciences. 



27. On the Use of Chloroform in the Treatment of Stricture of the Urethra with 
Retention of Urine. — R. J. Mackenzie, Esq., in a clinical lecture delivered in 
the Royal Infirmary, made the following interesting remarks on this subject: — ■■ 

In the treatment of ordinary stricture of the urethra, the use of chloroform 
is not called for. On the contrary, its employment, where no unusual irrita- 
bility of the urethra exists, must evidently be attended with disadvantage, as 
the feelings of the patient form, to a certain extent, a guide to the surgeon in 
passing the instrument through the constricted part of the canal. 

It is in the irritable form of stricture, accompanied with spasmodic contrac- 
tion of the muscular fibres surrounding the urethra, that advantage is occasion- 
ally derived from the use of chloroform. Cases of this kind occur, where, 
every now and then, during the treatment by dilatation, the progress of cure is 
checked for a time — a bougie of small size is tightly grasped in the stricture, 
which a day or two previously easily admitted a larger instrument. This diffi- 
culty appears to be caused by spasm of the muscular fibres surrounding the 
canal ; and it is in such cases that the use of chloroform decidedly facilitates 
the introduction of instruments. 

But it is when retention of urine occurs in cases of this kind, that the advan- 
tage of chloroform is more prominently marked, and of which, I think, the 
simple details of the following case give undeniable proof. 

James Pentland, aet. 23, admitted into the hospital, October 19, 1851, on ac- 
count of stricture, with retention of urine. He stated that for the last four 
years he had served in an infantry regiment, during the greater part of which 
time he had suffered from stricture of the urethra, on account of which he had 
been discharged, as unfit for military duty, a few months previously to the date 
of his admission into the hospital. He had repeatedly, whilst in the army, 
suffered from retention of urine, which had been relieved occasionally with 
great difficulty, and with very small-sized catheters, at other times with instru- 
ments of larger size. 

During the last month, his difficulty in making water has increased ; and on 
the day before his admission, he again suffered from retention, and the surgeon 
under whose care he had latterly been, and who had, on various occasions, 
passed instruments into his bladder, failed in introducing a catheter. The pa- 
tient was then sent to the hospital, where, after a good deal of difficulty, I suc- 
ceeded in passing a small catheter (No. 2) into the bladder, and removed a 
large quantity of urine. The catheter was tightly grasped, and an induration 
was felt by the finger at the seat of stricture — the bulb. The catheter was re- 
tained in the bladder for two days, when it was withdrawn, and he was able to 
pass his water easily in a small stream. 

On the 24th, at the hour of visit, I found him again suffering from retention. 
A large quantity of urine had accumulated, the bladder forming a prominent 
tumour, which reached nearly as high as the umbilicus. On attempting to in- 
troduce a catheter, I found I was unable to pass the smallest-sized instrument 
through the stricture. No. 1 was passed within the constricted part of the 
canal so far that it could not be withdrawn without using a considerable degree 
of force ; but, after repeated trials, I was foiled in reaching the bladder. 

Under these circumstances, I was about to request the assistance of Mr. Syme, 
who was in the hospital at the time, when it occurred to me that the case was 
a good one to test the existence of muscular spasm by the use of chloroform. 
After inhaling the vapour for a few seconds, the patient became much excited, 
and struggled a good deal ; but no sooner had the stage of excitement passed 
off, and the relaxed state of the muscles and stertorous breathing evinced the 
full action of the anaesthetic, than the urine was expelled in a forcible and con- 
tinuous stream by the side of the small catheter, the point of which I had re- 
tained within the constricted part of the canal. I immediately withdrew the 
catheter, which now lay loosely within the canal, and at once passed No. 2 into 
the bladder with perfect ease. 

After emptying the bladder, and before withdrawing the catheter, I requested 
one or two of the gentlemen who were present, and who had felt the tightness 
with which the smallest instrument had been grasped, to satisfy themselves 



1852.] 



Surgery. 



251 



that the larger catheter now lay loosely in the canal. I believe, indeed, that 
Nos. 4 or 5 might now have been passed as easily as No. 2. 

No further difficulty occurred in the treatment of the case. The contraction 
of the canal was overcome by gradual dilatation, and the employment of chlo- 
roform was not again required. On the 27th, No. 2 only could be passed. On 
the 29th, Nos. 2 and 3. On the 1st of December, the patient was dismissed 
from the hospital, No. 16 having been passed two or three times before his 
dismissal. He returned to the hospital two or three times afterwards, when 
my house-surgeon, Mr. Moir, found no difficulty in passing the largest-sized 
bougie. His urine was passed in a full stream, and his former symptoms were 
entirely relieved. 

In recording this case, it is not my wish to advocate the employment of chlo- 
roform as a general rule, even in those cases of stricture where considerable irri- 
tability of the urethra exists ; but to call attention to the distinct proof of the 
constriction in this case being much increased by muscular spasm, and of this 
being at once relieved by the action of chloroform, as well as to the fact that 
the bladder retained its expulsive power, whilst the retentive muscular fibres 
were relaxed. 

The involuntary evacuation of the bladder is a frequent effect of the inhala- 
tion of chloroform, which is not difficult of explanation. The tendency of the 
bladder to contract, when moderately distended with urine, is resisted, whilst 
the individual retains his senses, by an effort of the will, by the contraction of 
voluntary muscular fibres. Under the full influence of chloroform, the volun- 
tary muscles are paralyzed, but the involuntary muscles retain (unless the 
inhalation is carried to a poisonous extent) their contractile power. The mus- 
cular movements of respiration and circulation continue. The contractions of 
the uterus in parturition are only partially, if at all, impaired ; the bladder in 
the same way retains its expulsive power. In the operation of lithotomy, we 
see the urine expelled through the opening in the neck of the bladder with the 
same force when the patient is in a state of complete anaesthesia, as when chlo- 
roform has not been inhaled. The organ, though deprived of sensation by the 
action of the chloroform, retains its sensibility to its natural stimulus, and re- 
tains, at the same time, its contractile power. The muscular fibres, which, in 
a state of health, resist, through an effort of the will, the expulsion of the 
urine, are, in irritable stricture, spasmodically contracted. The spasm is re- 
lieved by the action of the chloroform, and the resistance to the flow of urine 
being thus removed, the bladder expels its contents. 

Professor Simpson has kindly furnished me with the notes of a similar case, 
which occurred in the practice of Mr. Creeke, of Leven, whose account of the 
case is as follows : — 

" A young sailor, robust and active, aged 25, applied to me, September 14, 
1851, not having voided urine for twenty hours. He has had a stricture for 
some years, and had a very small catheter introduced in Bombay about eighteen 
months ago. He had not much difficulty in making water during his voyage 
from India, and has lived rather freely since his return home. 

" Finding all attempts at introducing a catheter useless, I proposed to admi- 
nister chloroform, but to this he demurred so strongly as to induce me to con- 
sult my friend Dr. George Forbes, of Kennoway, who also attempted the intro- 
duction of the catheter without success. The administration of chloroform was 
again proposed, and, as he was suffering considerably from distension of the 
bladder, he consented. The chloroform vapour was then inhaled for about a 
minute, when he exclaimed, 'I'm all right now!' In fact, he was passing 
urine quite freely (allowing for the organic lesion before spoken of). I kept 
xip the action of the chloroform slightly, and he emptied the bladder to his 
astonishment and great relief." 

The account of these cases proves, I think, the value of chloroform as an 
auxiliary to the introduction of the catheter, or even as a means itself of reliev- 
ing the distended bladder. It acts in the same manner as the warm bath, but 
much more speedily and effectually. Without its employment, I think it is 
not improbable that in both the above cases it would have been necessary to 
have opened the urethra from the perineum, or to have punctured the bladder. 
— Monthly Joum. of Med. Science, March, 1852. 



252 



Progress of the Medical Sciences. 



28. New Mode of Operating for Ovarian Dropsy. — Dr. I. B. Brown read be- 
fore the Medical Society of London, May 15, 1852, a paper on this subject. 
His operation consists in excising a portion of the cyst, returning the remaining 
portion into the peritoneal cavity, and closing the wound by sutures, thus allow- 
ing any fresh fluid secreted by the remaining portion of the cyst to escape into 
the cavity of the abdomen, there to be taken up by absorption, and discharged 
by the kidneys. Mr. Brown said this method of treatment was suggested to his 
mind by reflecting upon the numerous cases on record, in which a spontaneous 
cure has occurred by an accidental rupture of the cyst, followed by a copious 
discharge of urine. This mode was not considered applicable to every case, 
nor was it the purpose of the author to lay down any absolute rules for its use, 
but simply to relate such facts as had come under his observation. 

Case 1. — This case had been alluded to on a former occasion, and Mr. Brown 
now read the notes of the case as they were taken by Mr. Bullock, at St. Mary's 
Hospital, where the operation was performed. The woman, aged forty-seven, 
was subject to prolapsus uteri, which Mr. Brown considered as presenting a suf- 
ficient objection to treating the case by pressure. The swelling first appeared 
rather on the left side, about nineteen years ago, but had increased rapidly dur- 
ing the last six months. The following was her condition on admission to St. 
Mary's Hospital, Feb. 13, 1852 : Abdomen considerably enlarged, with shoot- 
ing pains extending to the shoulders. Complete procidentia uteri, returned 
with difficulty. Percussion dull in front, resonant at the sides, less so on the 
left than the right ; fluctuation very distinct, the integuments moving freely over 
the tumour. — Feb. 14: Ordinary diet; porter, one pint; blue-pill, three grains; 
compound aloetic pill, four grains, every night, with saline diuretics. — March 
6 : General health good ; some fluid drawn from the cyst with a small trocar 
was quite clear, with only a trace of albumen and some chlorides. — 10th : She 
was placed under the influence of chloroform, and an incision was made through 
the integuments, down to the linea alba, from an inch and a half below the um- 
bilicus, extending four inches. The linea alba was then divided, afterwards 
the transversalis fascia, and finally the peritoneum ; the cyst was then presented 
to view, and found to be free from adhesions. It was seized by a pair of for- 
ceps, a large trocar was introduced, drawing off about sixteen pints of fluid, 
leaving some fluid in the cyst, and then a piece of the cyst which appeared com- 
paratively free from bloodvessels was excised. The external wound was closed 
by interrupted sutures, the ligatures including all the abdominal parietes ex- 
cept the peritoneum. She was ordered two grains of opium immediately, and 
one grain every three hours. A pad of wet lint was placed over the wound, 
and a broad bandage round the abdomen. Severe peritonitis ensued for the first 
five or six days, which was subdued completely by large and repeated bleedings 
from the arm, with calomel and opium. In eight days the abdominal tender- 
ness had subsided, the abdomen became flaccid, and the urine passed exceeded 
in quantity the fluid swallowed. — By the 21st (eleven days after the operation), 
the remains of the cyst could be felt on the right side of the cicatrix, as a solid 
substance of an irregular form. On the 3d of April, no increase of the abdo- 
men could be discovered, and on the 6th she was discharged. Mr. Brown said 
he expected that the kidneys would continue to secrete more fluid than was 
drunk for some time, and that the cyst would ultimately become of an indurated, 
perhaps calcareous character, possessing less vitality, and incapable of secret- 
ing fluid. He should feel himself bound to report to the Society any return of 
the disease, although he did not anticipate a relapse. 

Case 2. — In this case, which had been treated nine years ago by tapping, pres- 
sure, mercurials, and diuretics, so far successfully that no return of fluid took 
place for seven years, the abdomen had been gradually enlarging for the last 
two years, and the patient was anxious for a radical cure, and sanguine as to 
the result of the operation of excision of a portion of the cyst. She was pre- 
viously prepared for the operation by a farinaceous and milk diet, avoiding stimu- 
lants, and keeping the bowels well open daily, under which treatment the size 
of the abdomen was materially reduced. The operation was performed on the 
29th of March, 1852, in a manner similar to that related in Case 1. Nine pints 
of clear fluid were withdrawn, and a portion of the cyst excised. But it un- 



1852.] 



Surgery. 



253 



fortunately happened that the peritoneal coat of the cyst was very vascular, 
and hemorrhage ensued, which was not to be subdued by torsion of the vessels. 
As there were no adhesions, it was determined to remove the whole cyst. A 
double ligature having been tightly applied over the pedicle, which was attached 
to the left ovary, about an inch and a half broad, and containing one large 
bloodvessel, the pedicle was divided, the cyst removed, sutures applied, and over 
them a many-tailed bandage. The case did very well, no signs of inflammation 
occurred, the ligature came away in four weeks, and on the day following the 
patient was in her drawing-room convalescent. This case was related, as illus- 
trating an important difficulty which might occur, rendering the removal of the 
whole cyst a safer practice than tying several bleeding vessels, and leaving the 
ligatures within the peritoneum, a source of much danger. 

Case 3. — In this case the operation was performed in a similar manner to that 
detailed in Case 1. A portion of the cyst was excised, but a second large cyst 
was found, the fluid of which was evacuated, and the wound closed. An attack 
of inflammation ensued, which was successfully combated by bleeding, calomel, 
and opium, and the patient did well. The first cyst became collapsed, and could 
be easily felt beneath the walls of the abdomen ; but the second cyst has fre- 
quently filled since ; and now, sixteen months after the operation, it fills at a 
much slower rate, and the patient's health is much improved. Steady and firm 
pressure has been had recourse to after each tapping, to which Mr. Brown at- 
tributes mainly the slower filling of the cyst. This case was related to show 
another complication which might occur. 

Mr. Brown concluded by expressing a hope that this operation may prove to 
be another successful method of treating this very troublesome disease. — Lancet, 
June 5, 1852. 

29. €h°adual Reduction of Hernice long Irreducible. — M. Malgaigne adduces 
(Rev. Med. Chir., t. x. p. 179) two new examples of the efficacy of his plan of 
reducing old and voluminous hernise. This consists in subjecting the patient 
to a very low diet and purgation, applying ice or cold poultices to the tumour, 
and employing the taxis daily. One of these cases was an enormous inguinal 
enterocele, which had remained unreduced for several years, and now equalled 
in circumference the size of an ordinary hat. Complete reduction was obtained 
after continuing the above means for seventeen days. The other was an in- 
guinal entero-epiplocele, which had remained unreduced for seven years, and 
was reduced completely in six days. 

30. Circular Arterial Distribution around the Neck of a Direct Inguinal 
Hernia. — Prof. Rjzzoli operated on a patient for a large strangulated direct 
inguinal hernia on the left side. On passing his finger to the ring, in order to 
ascertain the locality of the obstruction, the professor found that, on whatever 
side he explored, it was met by a strong arterial pulsation. He only ventured 
to make several superficial scarifications, which were not deep enough to im- 
plicate the arterial branches, and gradually obtained sufficient dilatability to 
procure the return of the hernia. The intestine, indeed, from delay, was in a 
state of gangrene, and the patient died. At the post-mortem, the origin of this 
circular arterial pulsation was found to be as follows : The umbilical artery, 
rising from the external iliac, and continuing pervious, coursed up on the inner 
side of the ring, and sent two branches above the upper border of this. From 
the epigastric artery, which ran on the outer side, also sprang two branches. 
One of these coursed around the lower and inner side of the ring, so as nearly 
to surround it, and the other ran along its upper side parallel to the branch 
coming from the umbilical. An incision anywhere around the tissues of the 
neck of the sac would have given rise to fatal hemorrhage, so large were these 
branches. A diagram is furnished with the paper, and the preparation is pre- 
served in the Bologna Anatomical Museum. — Ibid., from Bull, delle Scienze 
Mediche, vol. xix. p. 143. 

31. Tracheotomy in Croup. — M. Trousseau, in a series of papers in V Union 
M6dicale (1851, No. 100), relates the cases in which he has most recently per- 

No. XLVIL— July, 1852. 17 



254 



Progress of the Medical Sciences. 



[July, 



formed tracheotomy for croup. Adverting to his entire experience upon the 
subject, he states that he has performed this operation altogether 169 times 
(11 for chronic disease of the larynx, and 158 for croup) ; and that 43 of these 
cases, or a little more than a fourth, have recovered. Among his last 18 cases, 
however, there have been 8 recoveries, or nearly one-half. The results obtained 
at the Hopital des Enfans have not been less satisfactory of late ; for, of 19 
cases operated upon, between January and August, 1851, one-half recovered; 
and M. Guersant has been as successful in his private practice. M. Trousseau 
believes that one reason of the greater success in later years is, that now the 
principles of treatment in these cases are better understood ; the children are 
brought to the hospital in a less exhausted state, their powers not having been 
lowered by the application of leeches and blisters, heretofore so common. Still 
more importance, however, does he attach to the modifications he has made in 
the treatment after opening the trachea. Thus, he has discontinued the appli- 
cation of a strong solution of nitrate of silver to the trachea and bronchi, which 
he used formerly to insist upon. He now, too, employs a double canula, so that 
the inner one maybe taken out and cleaned when necessary, without disturbing 
the other ; and, after the wound is dressed, he covers all the parts over with a 
cravat, and thus avoids the difficult expectoration and desiccation of the mucus 
which occurred when they used to be left exposed. — B. and F. Med.-Chirurg. 
Rev., April, 1852. 

32. Autoplastic Treatment of Ranida. — M. Forget relates (Memoires de la 
Society de Chirurgie, t. ii., Paris, 1851) two cases of ranula, in which he suc- 
cessfully employed a modification of M. Jobert's stomato-plastic procedure. He 
prefaces the narration by a defence of the opinion generally entertained, that 
the affection is due to an obstruction or obliteration of the salivary ducts. This 
view is opposed by those observers who regard ranula as always resulting from 
an accidental cyst, analogous to the closed cavities in other parts of the body 
(examples of such sublingual cysts, simulating ranula, are indeed met with) ; 
and by Stromeyer and Fleischmann, who regard it as the abnormal increase of 
a natural bursa. M. Maisonneuve denies that any positive cases of salivary 
ranula are on record, inasmuch as obliteration or obstruction of Wharton's canal 
is attended with inflammatory action, which is not found in ranula; but the 
occurrence of this inflammatory action, in fact, much depends upon whether 
the obstruction has been suddenly or slowly produced. The great dilatability 
of Wharton's duct is amply proved by the size and number of the calculi that 
have been found within it. From M. Forget's view of the nature of the affec- 
tion, it follows that the various means employed for the relief of the affection 
should have in view, not the obliteration of a cyst, but the re-establishment of 
the course of the saliva, by means of a permanent artificial opening ; and it is 
to this end that M. Jobert's operation is directed. 

Before adverting to its application in the two cases in question, we may just 
refer to a very interesting clinical lecture on ranula recently delivered by M. 
Jobert himself.* In this he observes that great confusion in treating the dis- 
ease has resulted from confounding, under the term " ranula," all the cystiferous 
tumours developed at the side of the tongue. To obviate this, he terms ranula 
arising from obstruction of Wharton's duct "salivary ranula," while he applies 
the term " mucous ranula" to the tumours which by their external appearance 
simulate this. When the obstruction of Wharton's duct is complete, an acute 
salivary ranula may form very rapidly and assume a large size, raising the 
tongue and projecting the submaxillary gland at the side of the neck. The 
mucous ranula (in M. Jobert's opinion the most frequent form) is composed of 
a cyst developed in Fleischmann's bursa at the root of the tongue, behind the 
fraenum. In the majority of cases, it projects more on one side than the other. 
Owing to its depth, the tumour is not transparent, unless very recent and 
tensely distended. When of old formation, and after being subjected to re- 
peated operations or attacks of inflammation, the walls become thickened, so 
as even to acquire a fibro-cartilaginous consistency. Developing itself at first 



* Gazette des Hopitaux, No. 100, 1851. 



1852.] 



Surgery. 



255 



in the mouth, it eventually appears in the cervical region, giving rise to a 
tumour on each side of the median line. Fluctuation may then become as dis- 
tinct in the neck as in the mouth ; and the fluid may be pressed from the one 
part to the other. A third form may be termed the follicular ranula, resulting 
from an obliteration of one or more of the canals of the mucous follicles. It is 
superficially situated, and almost always multiple, consisting of several small 
tumours in immediate proximity ; or, if single, it is very irregular. At first it 
is rounded, but soon becomes pedunculated. It is quite transparent. 

In M. Forget' s first case, the tumour had previously been once punctured, 
and once punctured and cauterized, two months since ; and had now again 
reached a very inconvenient size at the right side of the mouth. 

" I commenced by rendering the entire external surface of the tumour raw 
by means of a superficial dissection, which implicated the mucous membrane, 
but not the cyst itself. I extended the dissection as far as possible, and obtained 
a raw surface at the floor of the mouth, which reached beyond the circumference 
of the tumour. Next, the cyst was opened by an incision extending through 
its entire length, parallel to the body of the lower jaw, an abundant albuminous 
fluid being thus discharged. I then introduced the extremity of my finger into 
the cavity, and ascertained that it terminated in an infundibulum, which was 
prolonged backwards from the centre of the jaw in the direction of the conduit 
of the submaxillary gland. Concluding from this that the tumour resulted from 
a dilatation of the duct, and not from a cyst unconnected with the salivary pas- 
sages, I continued the operation. The incision of the tumour had furnished 
two flaps, and I divided each of these in the centre, so as to obtain four of a 
tolerably regular triangular shape, and which were free and floating in all their 
extent from base to summit. Having carefully waited until all bleeding had 
ceased, I next fixed these flaps in proper position, turning each from within 
outwards, and commencing with the two nearest the tongue. One of these was 
laid in the sublingual groove, and maintained there by two points of suture, the 
other being carried beyond the frasnum, and secured in the same way. The 
two anterior flaps were then adapted to the buccal floor. For these last, one 
point of suture, applied to the summit, sufficed; while, for the other two, in ad- 
dition to this, a second suture was applied at that edge which corresponded to 
the raw edge of the mucous membrane, with which they were brought in 
contact. The immediate result of the operation was to maintain the salivary 
cavity widely open, so that the end of the little finger easily entered it. ;; — 
p. 229. 

Considerable tumefaction of the flaps and neighbouring mucous membrane 
ensued, requiring frequent and free application of nitrate of silver during a 
week. The sutures were removed two days after their application. At the end 
of five weeks the cure was complete ; and M. Forget has since had repeated 
opportunities of assuring himself that it has continued permanent. The floor 
of the mouth is as flat on the one side as on the other, and under the tongue an 
elliptical opening exists, which easily admits a small probe, and from which a 
fluid, having all the characters of saliva, flows. The inflammatory swelling of 
the flaps would have obliterated the opening, if the aperture, during the treat- 
ment of the case, had not been frequently dilated, and the adhesions broken 
down by a probe. In the second case the swelling had reached the size of an 
egg. The operation was performed in the same manner ; but during the cau- 
terization that was resorted to, to diminish the tumefaction of the flaps, stoma- 
titis was excited, which produced a sublingual tumefaction or commencing 
ranula on the opposite side ; which, however, disappeared with the inflammation 
that had caused it. For many days the opening manifested a great tendency 
to close, but was prevented from doing so by the daily introduction of a probe, 
for two or three weeks. — Ibid. 

33. On Opening Buboes by Multiple Punctures. — M. Vidal strongly recom- 
mends that venereal buboes should not be allowed to open of themselves ; for 
when they are left to nature, the skin becomes detached, and thinned, a great 
loss of substance ensues, a tedious recovery takes place, and an unsightly 
deformity is left. Opening by caustic, too, leaves disfiguring scars ; and the 



256 



Progress of the Medical Sciences. 



same inconvenience results from large incisions, and cutting away, by the 
bistoury, portions of skin that are too much changed to unite. Still the bis- 
toury is much more easily managed than is the caustic, and M. Vidal much 
prefers removing by it a portion of half dead, detached skin, or a gland which 
is an obstacle to reparation, to attacking such parts by caustic. By its aid the 
cicatrix may be rendered more regular, and cause less deformity. But cases 
requiring large incisions and excision are rare, especially if the bubo be early 
treated, and punctures are made as soon as matter is formed. 

The bubo should be shaved, and any remains of plaster, &c. removed. A 
straight, narrow bistoury, or even a lancet, may be employed. If the abscess is 
recent, and suppuration not extensive, one puncture at the fluctuating point may 
be employed, as a single gland may be then inflamed, and we thus discharge 
the pus from it. The other glands are only engorged ; but if they afterwards 
suppurate, they must be treated in like manner — so that in this way we may 
have to open three or four of them in succession, especially in scrofulous sub- 
jects. When the abscess is intra-glandular, its deeper seat renders it more 
difficult of recognition ; and it is far better opened by a straight bistoury, which 
also acts as an exploratory instrument, than by caustic. If the collection be 
both extensive and superficial, several simultaneous punctures are required. 
These must not be practised in the thin skin of the fluctuating centre, but at 
the circumference. The bistoury is passed in obliquely, and guided subcuta- 
neously towards the centre, arriving thus at the pus by a circuitous route. In 
this way, we divide the skin only where it is adherent, intact, and possessed of 
its vitality ; while if we penetrated the denuded, half dead, and thinned skin 
of the centre, there would be danger of the apertures enlarging by mortification, 
and approximating to each other so as to constitute a large breach of surfaces 
giving admission to the air, and being followed by all the disadvantages of 
large openings made by the knife or caustic. The bubo must not be pressed 
for two days after making the punctures, and it will then gradually discharge 
itself, the space being filled up in proportion as the pus is evacuated, and the walls 
of the abscess are retracted. The cure is rapid, and after its completion not a 
trace of the disease is left — the cicatrices which remain not showing more than 
leech-bites, and like them eventually disappearing. Sometimes the little 
oblique tracts made by these punctures become obliterated before the pus is 
completely evacuated ; but as it is rare for them all to do so, we may, by gently 
pressing the tumour once a day, discharge the pus by such of them as remain 
open — this compression being uncalled for during the first day or two, when 
the tracts are free, and the pus abundant. Occasionally, all the tracts show a 
great tendency to close up, and it is preferable to allow them to do so, rather 
than apply tents to keep them open — making one or two new punctures if re- 
quired, which is not always the case, as the remaining pus is sometimes reab- 
sorbed. — Brit, and For. Med.-Chir. Rev., Jan. 1852, from Bulletin de Th6ra- 
peutique, vol. xli. 

34. On Ununited Fracture. By Prof. Syme. — There are at present under our 
observation four cases of ununited fracture. Two of these were sent from dif- 
ferent parts of the country, as hopeless objects of ordinary treatment — the long 
period of nearly six months having elapsed since the occurrence of their re- 
spective injuries. They were both admitted on the same day, about two months 
ago ; and I then explained that the great source of such conditions being the 
want of sufficiently complete rest during the period of consolidation, I enter- 
tained a sanguine expectation of effecting reparation through the maintenance 
of absolute immobility of the broken bones. I stated that ununited fracture 
of the humerus might be regarded as nearly, if not altogether, irremediable by 
any means hitherto contrived, and that this was fortunately of little consequence, 
as the muscles of the limb were so equally balanced as to render it useful for 
most purposes, notwithstanding the defect of rigidity. But in regard to the 
other bones liable to this derangement, and more especially those of the thigh 
and leg, which are most frequently the subject of it, I was able to say that, in 
the course of five-and-twenty years' hospital and private practice, I had always 
succeeded in restoring firmness, by mere attention to the insurance of stability 



1852.] 



Surgery. 



257 



in the position of the limb ; and I expressed a strong impression, almost amount- 
ing to conviction, that various means of remedy, such as setons, subcutaneous 
division, ivory pegs, etc., owed any share of credit which they had acquired to 
the care, conjoined with their employment, to keep the bones quiet. The plan 
I have pursued is founded upon there always being in such cases more or less 
deformity, from the yielding state of the bone no longer resisting any excess of 
muscular contraction that may exist on one side of the limb. There is thus 
established a preternatural convexity, upon which I place a cushion or folded 
sheet, and upon this — after being secured in its place — a splint of wood, long 
enough to extend, in the case of the leg, from the knee to the ankle ; and in 
that of the thigh, from the ribs to beyond the foot. Bandages are then applied 
above and below the cushion, so as to draw the distorted limb towards the 
splint, and render it not only straighter, but at the same time completely im- 
movable. In many cases of six, eight, or even twelve months' standing, the 
application of this simple principle has proved completely successful, and, as 
already stated, I have never found it necessary to employ any other measure. 
The two patients now under treatment — in one of whom the thigh, and in the 
other the leg, are concerned — have been much slower than usual in their pro- 
gress towards recovery, but are now very nearly quite strong, and the limbs, 
which were much deformed, are perfectly straight. In the third case, at pre- 
sent under our observation, the fracture is seated a little below the neck of the 
humerus, in a patient who suffers from palsy of the deltoid and other muscles, 
which has doubtless prevented reunion by not exercising the usual bracing 
effect upon the broken surfaces, and renders the prospect of recovery even more 
than usually hopeless. The fourth case has been treated, from its com- 
mencement, in the hospital — the patient being a young man, J. C, aged 18, 
who was admitted on the 10th of January, for compound fracture of the leg. 
A large portion of the tibia was detached at the time of the injury, and an ad- 
ditional portion subsequently exfoliated. The greatest care was taken to keep the 
limb quiet in a good position, and everything went on favourably, except that no 
firmness was regained. The wound has been healed for many weeks, but still the 
bone remains flexible, as if there were a fibrous substance interposed between its 
extremities. My explanation of this result is, that the fibula not having sus- 
tained a loss of substance commensurate with that of the tibia — or rather any 
loss of substance at all — has maintained the leg of its original length, and pre- 
vented the surfaces of the tibia from approximating to each other within range 
of the ossific action — just as in the experiments of Sir A. Cooper on dogs and 
rabbits, where a portion of only one bone of the foreleg was removed — it being 
always found that when the portion removed exceeded a small limit, the osseous 
extremities were united by a fibrous medium. According to this view of the 
case, the most likely mode of affording relief would seem to be cutting out the 
fibrous substance which has been formed between the ends of the tibia ; and, 
at the same time, in order to promote their requisite approximation, removing 
a portion of the fibula. Such an experiment appears justifiable under the cir- 
cumstances, and shall forthwith be put to trial. 

By a curious coincidence, you have here another opportunity of seeing the 
effects of ununited fracture ; and having already witnessed it in the arm, leg, 
and thigh, now see it in the forearm. The patient, a man aged twenty-four, 
tells us that his arm was broken six weeks ago, and has been treated carelessly. 
There is now a distinct convexity backwards, with swelling of the limb, and 
nearly complete loss of power in it. Both bones appear to have been fractured 
about the middle of their length, and there is here a slight degree of mobility. 
In these circumstances, I expect you will have a favourable instance of the 
treatment lately recommended — which consists in fixing a cushion over the 
convexity, applying over this a splint, and then drawing the ends of the bones 
towards it, so as gradually to render the limb straight — and constantly maintain 
the broken part perfectly free from motion. — Monthly Journ. Med. Science, 
June, 1852. 

35. Treatment of Ununited Fracture by the Application of Tincture of Iodine. — 
Professor Blasius communicated, in 1847, an account of the success he had 



258 



Progress of the Medical Sciences. 



obtained in the external application of iodine in pseudarthrosis ; and in the 
present paper he furnishes three other cases. The first was a healthy soldier, 
aged twenty-eight, who had suffered a simple fracture of the tibia and fibula.' 
The ends of the bones had continued movable for sis months, when the following 
tincture was ordered to be applied externally, night and morning: R. — Iodin. 
9j ; iod. pot. gss ; S. V. R. §j. In three weeks the callus was completely con- 
solidated. In the second case, the fragments of a fractured femur (occurring 
in a soldier, aged twenty-three) remained movable after thirteen weeks; but 
became quite firm after three weeks' pencilling with the iodine. The third case, 
occurring in a boy twelve years of age, was equally remarkable. — Ibid., from 
Med. Zeitung, 1851, No. 39. 

36. Dislocation of the Clavicle Backwards. — Two cases of this comparatively 
rare accident have been reported recently. 

The first is by M. Foucard [Revue Medico- Chirurgicale, Feb. 1851), which oc- 
curred in a woman who, while endeavouring to move a cart by pushing against 
the wheel, got jammed between the wheel and the wall. She was bled next 
day, but her symptoms becoming severe she was subsequently minutely ex- 
amined. It was then found that, in the place of the natural projection of the 
head of the right clavicle, there was a distinct hollow, and it was evident that a 
luxation backwards had taken place. The author made many attempts to re- 
store the bone to its place, but without avail, and therefore contented himself 
with subduing the inflammation by leeches. The patient recovered, and now is 
only conscious of the accident when she is called upon to make unusually great 
exertion. 

The second is by Mr. Sibley [Med. Times and Gazette, April 24th, 1852), and 
in this reduction was easily effected. 

The subject of this was a girl aged 10, who was admitted into Middlesex 
Hospital, March 10, under the care of Mr. De Morgan. It appears that, while 
playing in the street with some other girls, a carriage driving rapidly by at the 
time knocked her down ; but it is stated by those who saw the accident that 
the wheels did not pass over her. At the time of admission, was much col- 
lapsed ; face pale ; skin cool, with slight rigors ; suffering from great dyspnoea ; 
respiration anxious, 44 ; pulse 100, feeble. The head is drawn down on the 
chest, and there is extreme pain when it is raised. On exposing the chest, there 
is seen considerable tumefaction over the right coracoid process, and about the 
external half of the right clavicle, with some bruising of the integument. The 
inner end of the left clavicle may be seen distinctly projecting beneath the 
skin ; but in place of a similar projection on the right side, there is a depres- 
sion, into which the finger maybe thrust, and the clavicular articulation of the 
sternum felt ; this, however, causing great pain and increased dyspnoea. Be- 
hind this notch in the sternum the clavicle may be felt, so that the inner end 
of the bone lies behind the sternum. There is a difference in measurement 
from the middle line to the acromion of a quarter of an inch in favour of the 
left side ; there is also considerable bruising over the right side of the lower 
jaw, a slight cut over the right ear, with a more severe one over the left, and a 
severe laceration of the left little finger. 

On placing the knee against her spine, and gently drawing the two shoulders 
backwards, the bone is easily restored to its proper place, causing obvious relief 
to the dyspnoea ; but immediately on leaving hold of the shoulders, the bone falls 
back, and the dyspnoea returns. A splint was then placed across the shoulders, 
with a pad between it and the spine, the shoulders being drawn to the splint by a 
bandage. By this means, the bone was kept firmly in its place ; pillows were 
so arranged along the child's back that the splint should not feel uncomfortable. 
On the apparatus being fixed, she could lean her head backwards, and stated 
that her pain was much relieved. 

She continued to wear a splint till a fortnight after the accident ; the bone 
then feeling quite firm in its place, she was allowed to lie in bed without a 
bandage. Ultimately the articulation became as firm as on the other side. 

37. Foreign Bodies in the Air-Passages. — The following is a summary of the 



1852.] 



Surgery. 



259 



principal conclusions with which M. Jobert terminates a series of papers 
founded on clinical and experimental observation : — 

1. Foreign bodies tend especially to lodge in the right lung, owing to the 
direction and dimensions of the bronchus of that side. 2. They penetrate when 
the chordce vocales are most widely separated, and a strong column of air rushes 
into the trachea, as occurs during the rapid inspirations and expirations in the 
action of laughing. 3. They traverse the superior apertures of the larynx, 
without raising the epiglottis, which is never closed down upon this, as has been 
stated. 4. The epiglottis is always raised by virtue of its own elasticity ; and 
its chief office seems to be to direct the passage of certain articles of food, as 
along a gutter, during deglutition. 5. The bodies traverse the air-passages 
rapidly, by reason of the laws of gravity, the impulse of the column of air, and 
their own nature. 6. They are only temporarily arrested at any particular 
point, and may change their place, until they have excited the inflammatory 
process, which enables them to hollow out a receptacle, in which they become 
lodged. 7. A peculiar sound is engendered by their presence ; and the bron- 
chial secretion is always increased, and may become sanguinolent. 8. A louder 
respiratory sound, and a more extended vesicular murmur, are heard on the 
opposite side, than on the side in which the body is placed. 9. Foreign bodies, 
whose size exceeds four lines in all directions, cannot be expelled by the sole 
efforts of nature, which are only efficacious in the case of very small ones. 
10. In dogs, on the other hand, in whom the glottis is on a level with the upper 
aperture of the larynx, the expulsion of foreign bodies easily takes place, by 
reason of the dilatability and dimensions of the aperture. 11. In the dead body, 
foreign bodies pass the glottis with difficulty, even when aided by the impulse 
derived from a considerable column of air. 12. In the living body, they have 
to overcome, not only this passive resistance, but the very active resistance of 
the constrictor muscles of the glottis. 13. It is only quite exceptionally that 
the operation of tracheotomy can be dispensed with; and it should be resorted 
to as early as possible, in order to prevent inflammation, local changes, and 
rapid or slow asphyxia. 14. It is a delicate operation, which should be per- 
formed by the successive division of all the tissues, and not by an incision 
comprising all or the greater part of the soft parts of the region at once. This 
is the best means of preventing hemorrhage, the introduction of air into the 
veins, lesion of the thyroid body, &c. 15. The trachea should be as widely 
opened as possible, so as to facilitate the escape of the foreign body. 16. We 
can only be certain that the trachea has been opened, when the air escapes 
with its characteristic sound. 17. When the foreign body does not issue on 
the opening being made, we must wait awhile, and excite the sensibility of the 
trachea by the introduction of a blunt body, so as to cause cough and expulsive 
efforts. 18. The trachea must be more largely opened, when a foreign body of 
a nature to swell from moisture has been long retained. 19. Reunion may be 
obtained by the primary or secondary intention. 20. The union by primary 
intention maybe obtained by simple compression, or by the interrupted suture, 
this only implicating the dartroid lamella that surrounds the trachea. 21. Ag- 
glutination may be produced by another procedure, which consists in traversing 
the walls of the trachea entirely, or in part, leaving the sutures hanging ex- 
ternally, these coming away from the fourth to the thirteenth day. 22. A 
plastic production serves as the means of union between the lips of the wound. 
23. Cicatrization only takes place by means of an intermediate production, and 
not by the direct fusion of the lips of the trachea. 24. The suture comprising 
the thickness of the walls of the trachea may excite inflammatory action both 
within and without the canal, and give rise to organized fistulas and encysted 
abscesses. 25. The suture which only implicates the covering, or a portion of 
the thickness of the trachea, only induces a plastic inflammation, and is to be 
preferred. — L 'Union Medicate, 1851, No. 68. 

38. Statistics of Operations for Cancer. — The Professor of Surgery (Mr. 
Paget), in his first lecture upon " Malignant Tumours," at the Royal College 
of Surgeons, made the startling announcement that persons operated upon for 
cancer died, upon an average, thirteen months sooner of their disease than 



260 



Progress of the Medical Sciences. 



[July, 



those who were not operated upon. The average was taken from upwards of 
sixty cases, at the same time omitting all those who died from the immediate 
effects of the operation. — Prov. Med. and Surg. Journ., May 26, 1852. 



MIDWIFERY. 

39. Chlorosis of Pregnancy. — M. Cazeaux recently read at the Paris Medical 
Society a paper, the object of which was to show, " that hydrgemia or serous 
polysemia is the most frequent cause of the functional disturbances in advanced 
pregnancy usually attributed to plethora." The analysis of the blood of preg- 
nant women exhibits a diminution of globules and an increase of water, differing 
indeed only from that of chlorosis by containing an increased quantity of fibrin. 
The quantity of fibrin is far less than in phlegmon, and the buff it gives rise 
to has been often observed in the chlorotic. The functional disturbances of 
pregnancy resemble those of chlorosis, many of these indeed being common to 
plethora and chlorosis. The effect of treatment confirms this view of their 
nature; for while here, as in chlorosis, depletion may prove a temporary and 
fallacious means of relieving serous plethora, it is from the employment of ani- 
mal food and iron that real benefit is obtained ; and this even in cases wherein 
local bleeding may be deemed advisable. M. Cazeaux does not, however, deny 
that true sanguineous plethora may be met with occasionally, and especially in 
the early months. 

During the animated discussion which followed, M. Duparcque admitted that 
pregnancy may occasionally induce a condition analogous to chlorosis ; but he 
referred to the marked power of venesection in arresting threatened abortion 
from active uterine congestion; and believes that the practice followed by our 
predecessors of bleeding at the middle of pregnancy, on account of the then 
active disposition to abortion, may often be advantageously imitated. A similar 
plethoric determination takes place at the seventh and ninth months ; and when 
the mother does not suffer ill effects from this, it may produce cerebral apoplexy, 
or that state of general congestion termed asphyxia, in the infant — the plethora 
killing the child, though it spared the mother, when precautionary venesection 
had been neglected. Puerperal convulsions might often be prevented, if bleed- 
ing were instituted for the plethoric condition in which they so frequently origi- 
nate. In judging of the presence of plethora, too much weight has been attached 
to the highly-coloured condition of the skin, especially that of the face and its 
adjoining mucous membranes, and to the projection of the veins. But it is very 
common to see persons who are constantly plethoric, and who are liable to 
phlegmasise, congestions, and hemorrhages, exhibiting so colourless a condition 
of the tissues, that from their mere aspect, we might believe them subjects of 
chlorosis. Such persons bear losses of blood, which those of a higher colour, 
and apparently eminently sanguineous temperament, could not endure. 

M. Jacquemier stated that he had examined the blood of about 200 women, in 
the eighth and ninth months of pregnancy, most of them being persons from 
the country. The so-called inflammatory crust was not met with so often as is 
usually supposed ; but occurred much oftener in winter (when many of the 
women suffered from bronchitis and influenza) than in summer ; it being met 
with at this latter period only once in six or even in nine cases. Most frequently 
when the buff did exist the clot was pretty large and softish, and the serum was 
not in excess ; the hard, retracted clot, covered with a thick buff, and bathed in 
a large quantity of serum, as seen in inflammation and chlorosis, being rarely 
met with. According to his observations, the excess of fibrin, whether absolute, 
or relative to the diminution of globules, is not considerable enough to habitu- 
ally give rise to the production of the inflammatory crust. The diminution of 
globules is infinitely greater in a chlorotic person than in a pregnant woman ; 
and all the analogy that can be traced between the two conditions may be stated 
in the fact, that a considerable number of women, after the middle period of 



1852.] 



Midwifery. 



261 



pregnancy, exhibit the commencement of ansemia. Clinical observation does 
not favour the view of the identity of the two conditions. Among many hun- 
dreds of women auscultated at the Maternite, during the last two months of 
pregnancy, M. Jacquemier only met with the carotid souffle in two or three. — 
Brit, and For. Med.-Chirurg. Rev., April, 1852, from Rev. Mddicale, 1851, vol. 
i. p. 553 ; vol. ii. p. 51. 

40. Two Cases of Females wlio had attained the Age of Forty-eight Years without 
having Menstruated. — Dr. Henry Oldham has recorded [Med. Times and Gazette, 
March 27) the two following cases, the only instances he has met with of non- 
menstruation, the females having passed the age for menstruation. 

Case I. — Maria B. appeared among my out-patients at Guy's, March 1, 
1851. Her immediate ailments were unimportant, but I was struck with 
her informing me that she had never menstruated. She was 48 years of 
age ; a tall, rather masculine woman, with large, full mammae, and a well-ex- 
panded pelvis. The upper lip was without hair, but some few hairs had grown 
upon her chin. She was married at 15 years of age, and her sexual desires 
had been natural, but she has been sterile. She had suffered occasionally from 
pelvic and abdominal pains, but there had been no regular menstrual or perio- 
dic uterine effort, or any supplementary flux of blood or other discharge from 
any mucous membrane of the body, Her general health has been good, and she 
has lived well, in the neighbourhood of London. 

The external sexual organs were fully developed, and the pubis was abund 
antly covered with hair, The vagina was a deep canal, normal in shape and 
healthy. The uterus was well placed, of natural weight and mobility, and 
the vaginal cervix well formed, but there was no os uteri; the site of the os 
could be felt by a slight dimpling, and by the speculum it could be seen ; but 
it was quite impervious, and some small bloodvessels appeared to pass over it. 

Case II. — Mrs. — called at my house in January, 1852, complaining of severe 
pains in the loins and lower abdomen — which had harassed her for some weeks 
— general feebleness of health, and dyspepsia. In the course of her history, it 
appeared that she had never menstruated ; and, at her request, I admitted her, 
under my care, into Guy's Hospital, January 28th, 1852, when the particulars 
of her history were taken by my clinical clerk, Mr. Massey, from whose report 
I have extracted the following detail. It may be remarked that her immediate 
ailments were relieved by a blister to the loins, tonic medicine, regimen, and 
rest ; and that she has just left the hospital quite recovered. Mrs. M, is forty- 
eight years of age ; of a light, delicate frame ; dark hair and eyes ; a native of 
Norfolk ; but a resident in London for the last twenty years ; in poor, and 
sometimes very reduced circumstances. She has been twice married ; both 
husbands have been healthy men, but she has been sterile, although her sex- 
lial feelings have been natural. 

Both before and since marriage she has had leucorrhoea ; at no time profusely ; 
but, since marriage, it has been muco-purulent ; sometimes yielded in small 
lumps; and has occasionally increased in quantity; but neither from the sexual 
organs nor any other part of the body has there been anything like a vicarious 
menstrual discharge. 

She has the aspect, form, and sexual development of a healthy person, with- 
out the physiological defect which she has suffered, and of which she is pain- 
fully conscious. The mammary glands are developed, and are sometimes ten- 
der, and yield a lactescent fluid. The pelvis is well expanded ; the pubis, labia, 
and external organs normally developed. The vagina is of normal size and 
shape, and the uterus well placed, movable, and free from any defect or dis- 
order, either congenital or acquired. She has a light soft hair developed on 
the lips, but not more than many other women ; and her voice is fairly modu- 
lated. 

These instances of non-menstruation are of rare occurrence. Retarded men- 
struation, even after the changes of puberty, have been well accomplished — a 
premature menstrual decline — long intervals of amenorrhea, and various forms 
of irregular menstruation, are met with in practice ; but that a woman wanting 
nothing but her menstrual function, and its correlative fecundity, should pass 



262 



Progress of the Medical Sciences. 



[July 



through life without any notable deviation from health is calculated to excite 
surprise. The history of these two cases shows a normal state of uterus (the 
closure of the os in one case being probably a late occurrence), vagina, external 
sexual organs, mammary glands, sexual instinct, and general physical and 
intellectual development, and an absence too of any compensating discharge 
in place of the menstrual flow. 

The perfection of the sexual organs allowed, in these cases, an unimpeded 
sexual intercourse ; and yet the prudence or even the propriety of marriage, 
until a female has menstruated, may well be questioned. 

41. Successful Case of Parturition in a Patient who had previously undergone 
Ovariotomy by a large Incision. By Johx Crouch, Esq. (Read before the 
Royal Medical and Chirurgical Society.) — Fanny Gould, the subject of this 
case, is now a fine healthy young woman, twenty-six years of age. In August, 
1849, I extirpated, by a peritoneal section of nine inches, a multilocular ovarian 
cyst, weighing fourteen pounds, and containing not less than two hundred 
separate cavities. The operation and its subsequent treatment are described 
in the 44th volume of the London Medical Gazette, and in the Provincial Medical 
and Surgical Journal for 1849. The tumour consisted of an hypertrophy of the 
left' ovary, the cells of which contained an albuminous fluid of various consist- 
encies. The fimbriated extremities of the left Fallopian tube were also much 
enlarged, and contributed a considerable portion towards the diseased mass. 
The patient's history from the above period is as follows : About five weeks 
after the operation she walked the distance of five miles, to inspect the prepa- 
ration of the tumour which had been extracted from her. During the winter 
the catamenia appeared at regular intervals, and her general health continued 
good, with the exception of an occasional pain in the left groin, and a slight 
difficulty in micturition, sometimes followed and relieved by a muco-purulent 
discharge in the urine. In April, 1850, she fulfilled an engagement made before 
the operation, and entered the married state. In January, 1851, the menses 
ceased, and in a short time subsequently the ordinary symptoms of pregnancy 
commenced. These were of a mild and healthy character — indeed, she never 
enjoyed existence more than during her period of gestation. The pain in the 
left groin opposite the part where the pedicle of the tumour had been tied, the 
difficult micturition, and the deposit in the urine entirely ceased. On the 9th of 
October, 1851, two hundred and eighty-two days from the termination of the 
last menstrual period, she was, after a lingering labour, safely delivered of a 
male child, weighing seven pounds. The infant was born in a state of asphyxia 
with the umbilical cord tightly encircling its neck; but soon after the pressure 
was removed, it showed symptoms of vigorous life. One fact connected with 
the cicatrix on the abdomen of the mother is not unworthy of notice. It was 
previously feared that the expansive powers of the parietes of the bowels would 
be impaired by so large a scar passing through their centre : I was therefore 
agreeably surprised to find that, not only did the surrounding skin dilate without 
tightness or puckering, but that the cicatrix itself increased in length three 
inches, and in breadth one-sixth of an inch, during the period of pregnancy ; thus 
affording an unusual and striking instance of the elasticity of newly-formed 
integument. 

Fanny Gould has now been confined nearly seven weeks, and both the mother 
and child are doing well in every respect. The cicatrix has returned to the 
same dimensions as before the pregnancy ; being five and a half inches in 
length, and one-quarter of an inch in breadth. — Lond. Med. Gaz., Dec. 1851. 

42. Rupture of the Vagina, with Passage of the Foetus into the Cavity of the 
Abdomen. By M. Daxyau. — This occurred in the person of a little, robust, 
bow-legged woman, 28 years of age. She had been already pregnant three 
times, delivery having on the first two occasions been accomplished by perfora- 
tion, owing to the great contraction of the entrance of the pelvis. On the third 
occasion labour was induced at the eighth month, and was followed by perito- 
nitis, iliac abscess, and puerperal mania. On the 18th of June, 1848, arrived 
at the end of her fourth pregnancy, she came to the hospital with commencing 



1852.] 



Midwifery. 



263 



labour pains. The liq. amnii had been discharged nine hours ; and under the 
influence of strong pains it was hoped that, owing to the small size of the child's 
head, the narrow orifice might be passed. The severity of the pains, however, 
rendered the woman very restless ; and while tossing about she fell off the bed. 
She resumed her place unaided, and declared she had received no hurt. How- 
ever, the pains at once ceased, the head could no longer be felt, the abdomen 
became very tender, and the woman's voice, pulse, and countenance underwent 
such alterations as to lead to the conclusion that the child had passed into the 
cavity of the' abdomen. M. Danyau, called to her one hour after, resolved upon 
attempting turning in preference to the Caesarian section. On passing in the 
hand, the uterus was found thrust upwards, a little forwards, and to the right 
— the entire left half of the vagina being separated from it. Owing to the small 
size of the child, its extraction was performed with more facility than had been 
anticipated — a perforation at the base of the cranium with Smellie's scissors 
sufficing to lessen the head sufficiently. The placenta was easily removed from 
the abdomen ; and no intestine descended through the vaginal aperture. No 
hemorrhage occurred ; but the patient seemed reduced to a state of hopeless 
exhaustion. She rallied, however, and in fifteen days, though advised to the 
contrary, she left the hospital. An examination per vaginam, made on the 
ninth and fifteenth days, furnished little idea of the severe lesion that had oc- 
curred — scarcely even any irregularity remaining at the place where the rup- 
ture had occurred, and the cervix uteri appearing just as it should do at the end 
of a fortnight. Soon after going out, she was seized with iliac inflammation, 
requiring antiphlogistic treatment, from which she completely recovered. 

M. Danyau refers to Goldson's work (1787), in which the author relates a 
case similar to the above, and collects various instances to show that many 
cases reported as examples of rupture of the uterus have really been examples 
of rupture of the vagina. This view was enforced in the treatise Be Rupturd 
Vaginas, published by Boer at Vienna, in 1812, in which additional confirmatory 
facts are adduced. All these cases have been republished in the Archives Gene- 
rales for November, 1827. M. Danyau has not been able to find many cases on 
record, narrated with sufficient exactitude to assure their identity with his own, 
as examples of rupture of the peri-uterine portion of the vagina, with passage 
of the child into the abdomen. Of the 17 cases to which these accounts refer, 
and in none of which gastrotomy was resorted to, 4 only terminated successfully 
— those of Ross, Douglas, Smith, and the author. In the 13 others, death re- 
sulted, either because the nature of the case was misunderstood, its progress 
too far advanced for interference — such interference being too long delayed — 
or from consecutive accidents, of which last, however, only one example is on 
record. The rarity of such consecutive accidents, and the successful issue of 
the 4 cases, teach the necessity of prompt decision, as well as careful examina- 
tion. — Brit, and For. Med.-Chirurg. Rev., April, 1852, from Mem. de la SocUte 
de Chirurgie, torn. ii. 

43. A Stethoscopic Indication of the Separation of the Placenta. — M. Caillant 
( TMse Inaugurate, Paris, 1852) informs us that, while engaged assiduously in 
the practice of obstetrical auscultation, it occurred to him to investigate the 
relations between the cessation of the placental bruit and the disruption of the 
placenta from the uterine surface. While thus occupied, he accidentally made 
the discovery of a peculiar and characteristic sound, heard immediately after 
the expulsion of the child, and which he at once attributed to the peeling off 
of the placenta. In order to ascertain with certainty that this sound was so 
produced, he has been in the habit of auscultating the uterus during the whole 
process of labour, and thus made out that the sound in question was only audi- 
ble immediately before the placenta was felt in the vagina. The sound consists 
in a repetition of cracklings, of considerable intensity, beginning and subsid- 
ing with each uterine contraction. It is said to be very different from the 
muscular bruit attending the contractions of the organ, as well as from the 
placental bruit itself, and more nearly resembles the dry crepitus of emphy- 
sema than any other known sound. — Prov. Med. and Surg. Journ., May 26, 
1852. 



264 



Progress of the Medical Sciences. 



[July, 



44. Hemorrhage from Inversion of the Uterus, in which the operation of Trans- 
fusion was successfully performed : with Remarks on the Employment of Transfu- 
sion generally. — John Soden, Esq., Surgeon to the Bath General Hospital, sent 
a communication, of which this was the title, to the Royal Medical and Chirur- 
gical Society. The author begins by expressing his belief that the evidence in 
favour of transfusion is not generally known, and that false notions prevail 
with respect to its dangerous character. Having had an opportunity three 
years ago of proving its power, he was induced to examine into the results of 
all the recorded cases, and has presented a table of thirty-six in which the ope- 
ration was performed in connection with the puerperal state. The thirty-sixth 
case was that in which transfusion was performed by himself. A lady was 
delivered of her third child rapidly, and the latter pains were so severe that 
the uterus was violently emptied of its contents, and became inverted; a gush 
of blood ensued, and the patient fainted. The placenta was detached, and the 
uterus returned ; no further hemorrhage took place. In half an hour the pa- 
tient had not rallied, and was insensible, cold, pulseless, and exsanguine in 
appearance; the breathing was at long intervals, stertorous, and jerking. She 
could just swallow stimulants by teaspoonful at a time, and every other means 
were used to restore her. After about an hour she became, however, worse; 
was no longer able to swallow, and the respirations became more rare and ster- 
torous. Transfusion was then had recourse to. The opening was made in the 
external cephalic vein, and blood drawn from the husband was injected by 
means of an ordinary syringe of German silver, with a detached stopcock, pre- 
viously well warmed. At first the blood would not pass, but returned through 
the opening in the vein ; presently the opposition, from the contact of the coats 
of the vein, seemed to give way, and the blood, though impelled by a steady 
and moderate pressure, rushed rapidly up the vein. The effect was instan- 
taneous ; a convulsion seized the whole frame, and the muscles of the face 
were frightfully distorted: not more than an ounce was injected. The convul- 
sions soon passed off, and the patient gradually recovered ; it was full an hour 
before any pulse could be felt at the wrist, and she did not recover conscious- 
ness till the following morning. During that time stimulants were continually 
given ; she remained for some time in a weak condition, but has since had 
another child, and is now doing well. The author then proceeds to analyze the 
table of cases, which shows that, out of thirty-six cases, twenty-nine were re- 
covered from imminent danger ; and it does not appear that in the fatal cases 
death was due to, or hastened by, the operation. In two, it may be presumed 
that death had occurred before the operation was performed ; in a third, only 
a small quantity of blood could be procured; in a fourth, no effect; in the fifth, 
there were marked but not permanent effects; in the sixth and seventh, the 
women were too much reduced to be restored. The author considers the influ- 
ence of the blood injected not to arise from the mere mechanical effect on the 
heart, but from a direct stimulation of the nervous system, and that the rapidity 
of the effect is modified greatly by the circumstances of the case, as regards the 
previous duration and cause of exhaustion, and by the character of the means 
used, as regards quantity, quality, and the mode of operating. With regard to 
quantity, it appears that a less amount was needed in proportion as the ex- 
haustion arose from the suddenness, rather than the amount of the bleeding. 
The author thinks, that some cases have been lost from a fear of introducing 
too much blood, the dangers of which, he thinks, have been over-estimated. 
The quality of the fluid he regards as of great importance, and he alludes to 
the impropriety of using the blood of the lower animals. The blood need not 
be drawn from one individual only ; that drawn from many may be taken, but 
it should be the blood of healthy persons. The want of success attending Dr. 
Simpson's cases of saline injection in uterine hemorrhage he attributes to the 
nature of the fluid used, while the same fluid might be serviceable in cholera, 
where the quality as well as quantity of the blood is interfered with. With 
regard to the mode of performing the operation, the author believes that a simple 
syringe, with a detached stopcock, plated or tinned on the inside, and capable 
of holding about three ounces, is the best instrument. The more compli- 
cated instruments, constructed to guard against the admission of air, he con 



1852.] 



Midwifery. 



265 



siders needless, as the danger is an imaginary one. In one case the operation 
was successfully performed with a common toy syringe. The operation should, 
however, be performed at the arm or in some distant vein, in preference to the 
neck, where there might be some risk from the entrance of air. The convul- 
sions which arose in the author's own case, he attributes, not to any irritating 
quality in the blood injected, but to the transition of the patient from a state 
of coma to that of syncope ; the same thing was noticed in one case three times 
on the exhibition of stimulants only, and before transfusion was performed. 
The author then proceeds to notice the opinions of writers on the subject of the 
treatment of uterine hemorrhage, and concludes by making a few remarks on 
the general application of transfusion, which has been equally beneficial in 
cases of hemorrhage from other causes, and in exhaustion from inanition. It 
has been, too, of temporary service in phthisis and in cancer of the stomach. 
Its use is suggested in the collapse of typhus and in the diarrhoea of children, 
where exhaustion is threatened. 

Mr. Barlow desired to ask a question respecting the case just read. He had 
understood that the beneficial effects had been produced by the injection of one 
ounce of blood. If that were all the blood used, it was, he thought, very sur- 
prising that such an extent of rallying should follow the employment of so 
small a quantity. 

The president remarked that the author was not present, and, therefore, 
could not furnish the desired information. With respect to the smallness of 
the quantity of blood used, there were many cases alluded to in the table, in 
which also a small amount only was injected with beneficial results. The 
strange blood admitted seemed to have the effect of rousing the nervous energy 
and the heart, showing that it is not the quantity of the fluid, but the stimulus 
that is required. In other instances, very large quantities of blood were trans- 
fused. 

No other remarks being offered by the fellows, the president applied to Dr. 
Robert Lee to furnish the Society with his opinion, and the results of his expe- 
rience with respect to transfusion. 

Dr. Lee had never seen transfusion of blood employed in any case of uterine 
hemorrhage, nor could he place much reliance on it in any of the varieties of 
flooding ; he did not believe that in the case before the Society the recovery of 
the patient could be referred to the introduction of an ounce of blood into the 
venous system. In accidental uterine hemorrhage, if the membranes be rup- 
tured early, and, that failing, if delivery be completed speedily by turning, the 
forceps, or craniotomy, and all the means in our power be employed to secure 
uterine contraction, comparatively few women will perish. He (Dr. Lee) had 
seen some recover where the symptoms were of the most alarming character, 
and recovery appeared absolutely impossible. In such cases, had transfusion 
been employed, the recovery would have been referred to it, and not to the real 
cause — the persevering and vigorous use of the ordinary remedies, pressure 
over the uterus, the external application of cold, and the internal administration 
of brandy, wine, and ammonia. In the hemorrhage which takes place after the 
uterus has been wholly emptied of its contents, the same remedies, if actively 
employed, are successful in a large proportion of cases. In most of the fatal 
cases of this description, which he (Dr. Lee) had seen, the common practice of 
introducing the hand into the uterus to excite it to contraction, by rubbing the 
inner surface, had been employed ; and he had also seen cases where fatal 
uterine phlebitis could be referred to the same plan of treatment, which does 
not succeed in exciting uterine contraction, when the patient is greatly ex- 
hausted from previous profuse loss of blood. This practice of rubbing the inner 
surface of the uterus with the closed fist is not merely inefficacious in the worst 
cases of atony of the uterus, but it actually displaces the coagula from the 
exposed vessels which form one of the principal means employed by nature for 
the permanent suppression of the hemorrhage. If proper compression be em- 
ployed over the hypogastrium, coagula can never form to distend the uterus, 
and, like a foreign body, prevent its contractions. Hemorrhage, to a dangerous 
extent, can never, he believed, take place where the uterus is contracted in the 
ordinary degree. The danger of uterine hemorrhage, from placental presenta- 



266 



Progress of the Medical Sciences. 



tion, is much greater than in the accidental variety ; but the mortality had been 
very considerably diminished in his practice since he had observed the fact, 
that in rigid conditions of the os uteri it is possible to seize the lower extre- 
mities of the child with two fingers, and deliver by turning, without introducing 
the whole hand through the os uteri. It is deeply to be regretted that an 
attempt, founded upon a grave anatomical blunder, should have been made to 
alter the practice established during the last century and a half in unavoidable 
uterine hemorrhage. The blood does not proceed from the placenta, as has 
been asserted, and it is, therefore, irrational and absurd to recommend tearing 
it away, or detaching it from the uterus with an iron instrument, and leaving 
the child within the cavity after having imprudently deprived it of life. He 
(Dr. Lee) had great faith in the established rules of practice in all the varieties 
of uterine hemorrhage. — Med. Times and Gaz., May 29, 1852. 

45. Sudden Death after Parturition. — Dr. Keith communicated to the Edin- 
burgh Obstetrical Society the following interesting case : — 

In November last, I attended Mrs. at her first confinement. The labour 

was very tedious, and as the pains were very severe, I kept her under chloroform 
for a longer time than I have done in any other instance — during thirteen hours, 
she was more or less under its influence. The slowness of the labour in the 
first stage was owing to the rigidity of the parts, and the early escape of the 
liquor amnii. As soon as the os uteri was fully opened, the head of the child 
descended into the pelvis : but, although no obstacle could be felt to its further 
progress through the passages, it remained for at least four hours making little 
or no advance, notwithstanding strong expulsive contractions. Under these 
circumstances, and fearing the infant might suffer from the long-continued 
pressure, I thought it right to have recourse to the forceps, by the aid of which 
the delivery was effected with great ease. I now found a second bag of mem- 
branes low down in the pelvis, and the feet of a second child presenting. The 
pains continued, and I brought away the second child, about twenty minutes 
after the birth of the first. It was a very small girl : the first was a boy of 
medium size. 

Both placentae were found detached, and came away at once. There was 
no loss of blood whatever after the delivery of the first child, but along with 
the two placentae an enormous quantity escaped. The uterus, however, con- 
tracted almost immediately, and the discharge subsequently was not more than 
usual. 

The effect of the sudden loss of blood was such that for a few rninu^ 
pulse could not be felt at the wrist ar all. The patient was still under chloro- 
form, but for a short time she seemed in a state of syncope. This very soon 
passed off; the pulse returned to the wrist: she slept for a short time quietly, 
and, on awakening, she showed no unusual symptom. 

From this time up to the fifth day she seemed to be making a fair enough 
recovery, if we consider the severity of the labour, and the quantity of blood 
lost. The discharge was natural ; milk appeared in the breasts, though in small 
quantity ; she took her food well ; and. with the exception of an acute pain, 
apparently of a neuralgic character, in the lower part of the back, for a few 
hours on the second day, she made no complaint of pain or even of tenderness 
anywhere. During this whole period, however, there was an unusual degree of 
restlessness, and an undefined feeling of discomfort, for which, though fre- 
quently asked, she could give no definite cause. The pulse was also faster than 
usual, and very small. These symptoms I ascribed partly to a naturally 
irritable and excitable temperament, aggravated by the shock of the labour, and 
the loss of blood, and partly to the heart's action being deranged by an unusual 
degree of flatulency, from a disordered state of the stomach and bowels. 

On the morning of the fifth day, the nurse told me that she had spent a good 
night, and her own principal request was that she might have a partridge for 
dinner. On feeling the pulse, however, it was much more rapid than on the 
previous day, and very feeble. As I could discover no other cause for this, I 
supposed she had been excited by the effort of nursing the child — an office 
which appeared to annoy her very much, and with which she would willingly 



1852.] 



Midwifery. 



267 



have dispensed. I, however, told the nurse, who had not the slightest appre- 
hension of any mischief, the state of the pulse, and asked her to send for me 
immediately if she saw any unfavourable symptoms. I left at ten o'clock, and 
at twelve an urgent message was sent to my house. As I was out at the mo- 
ment, Dr. Duncan was sent for ; and, at half-past twelve, he found her pulseless, 
and evidently sinking. I saw her half an hour later ; she seemed then to have 
very slightly revived, after taking a large quantity of champagne and brandy. 
The pulse was, however, quite gone at the wrist, the heart's action extremely 
rapid and feeble, the breathing very laborious. She was still perfectly sensible, 
and could speak without difficulty, and the extremities retained their usual 
warmth. Dr. Duncan suggested the presence of a clot in the heart, as the cause 
of the symptoms — an opinion which I at once adopted, as giving the only satis- 
factory explanation of the sudden sinking. Dr. Simpson saw her at half-past 
two o'clock. She died at three o'clock. 

The body was examined twenty-four hours after death, in the presence of Dr. 
Simpson, Dr. Duncan, and myself. On opening the abdomen, a large quantity 
of serum was found in the cavity of the peritoneum, and a very thin layer of 
very soft lymph covered some portions of the intestines. This was most unex- 
pected to myself, as I had entertained no suspicion whatever of the existence of 
peritonitis in even the slightest degree. The uterus showed no marks of inflam- 
mation, and was in all respects such as a healthy uterus would be at the same 
period after delivery. As the condition of the abdominal cavity appeared thus 
to show a sufficient cause for death, our expectation of finding a clot in the heart 
became less sanguine ; but, on exposing that organ, we found the right side 
unusually distended, and, on opening it, the right auricle was found quite filled 
with a large mass of fibrin, quite colourless; and, especially at one part where 
it adhered to the wall of the auricle, of a firm and almost leathery consistency. 
It appeared altogether different from the clot which is often found in the heart 
after a lingering death. I am inclined to believe that the serous effusion into 
the peritoneum was in a great measure the result of the mechanical obstruction 
to the return of the blood to the heart. In one of the cases mentioned by Dr. 
Meigs — who is the only author who has written on death from the formation of 
a clot in the heart after labour — death occurred in forty-eight hours, after 
severe loss of blood. During this time, he says, she suffered the most inex- 
pressible respiratory distress. " She filled her pericardium with serum, while 
her pericardial cavity became the subject of a great effusion." Upon examining 
the heart twenty-four hours after death, the right auricle and ventricle were 
filled with a firm whitish-yellow mass of fibrin, out of which every particle of 
colouring matter had been washed away. 

Dr. Meigs is of opinion that the clot is more apt to form in consequence of 
the patient, after having lost a large quantity of blood, incautiously raising 
herself, and bringing on a fit of fainting. I could not ascertain that my patient 
had fainted at all, except at the time I previously mentioned, immediately after 
the extraction of the placenta. Is it possible that the clot of blood had then 
begun to form in the heart, and had given rise to the unusual feeling of rest- 
lessness and malaise, and that it had continued to make very gradual increase 
till the morning of the fifth day, when the continued transmission of blood 
through the auricle became impossible ? 

Dr. M. Duncan remarked that the interesting point in this case was the 
peculiarity of the mode of death. When he first saw and examined the patient, 
she had none of the appearance of a patient sinking under puerperal fever in 
any of its forms. The symptoms were distinctly those of asphyxia, modified. 
There was the dinginess of skin, blackness of lips, with great respiratory dis- 
tress, and at the same time apparent freedom of the act of respiration. On 
carefully examining the hypogastrium, not the smallest amount of tenderness 
on pressure could be elicited. She was quite collected, answered questions 
with clearness, and complained only of the state of her breathing. These 
symptoms, he thought, were connected with the unusual clot found in the heart 
after death. 

Dr. Simpson considered the case as one of common puerperal peritonitis, in 
which the symptoms had been more masked than usual. The effusions found 



268 



Progress of the Medical Sciences. 



after death, in the abdomen and pelvis, showed the extensive nature of the 
peritonitis ; and the effusion was, he thought, semi-purulent. Dr. S. had written 
his " Thesis" to prove that peritonitis destroys, by depressing and arresting the 
heart's action — a doctrine long taught by Professor Alison. — Monthly Journ. 
Med. Sci., Jan. 1852. 

46. Sudden Death following Delivery. — At a meeting of the Chirurgical So- 
ciety of Paris, January 7, 1852, M. Robert introduced the subject of sudden 
death following deliveries without any apparent cause, the patients being to all 
appearance in perfect health. 

M. Robert gave the case of a young woman, aged 25 years, who, much excited 
by the political events of the times, went from Paris to Versailles, to be con- 
fined of her third child. Two days after her removal, she was safely delivered, 
and nothing particular followed; her recovery being most satisfactory until the 
ninth day, when, upon being assisted from her bed, and about to partake of a 
meal, she suddenly sank down and died. 

M. Robert had previously seen two similar cases. One, a young woman, non- 
primiparous, died on the sixteenth day — another, a woman who had borne several 
children, also died on the sixteenth day. The autopsy in these three cases showed 
nothing to account for death. 

Can these facts be considered as a simple coincidence, or is death determined 
by the modification which the puerperal state produces in the organization ? 

Do post-mortem examinations throw any light on the matter? 

M. Danyau replied that these facts are not very rare ; he had observed them 
many times. M. Dubois, M. Morence, and M. Baudelocque had each seen ex- 
amples. M. Danyau had attended a lady in the enjoyment of excellent health ; 
her labour was easy, and her recovery excellent; on the twentieth day, he visited 
her about 11 A. M.,and found her agitated and perplexed ; in a short time after 
which, she passed into an adjoining chamber, and there suddenly died. At the 
autopsy, no air was found in the veins or heart — the only pathological change 
worthy of note was a vascularity of the pericardium, and slight effusion into its 
cavity. M. Danyau remarked that in all known cases death had occurred in 
an equally rapid and unseen manner ; this patient was remarkably embonpoint. 
She took little exercise, and experienced oppression in walking; the heart was 
slightly fatty, a circumstance which had been noticed in England as predispos- 
ing to sudden death. Instances have been recorded of two women recently de- 
livered, dying from this cause ; but the causes have not been reduced to certainty. 
Death cannot be attributed to the introduction of air into the uterine veins im- 
mediately after delivery, for in that case death has always supervened rapidly; 
it is therefore evidently by extreme syncope. 

M. Robert had been lately making some observations on the blood of partu- 
rient women, and suggested the possibility of the predisposition to this fatal 
syncope arising from chloro-ansemic state of the blood. M. Danyau, on the 
contrary, was of opinion that there was no indication of chlorosis in any of the 
cases he had seen. — Monthly Journ. Med. Sci., March, 1852, from L' Union M6di- 
cale, Jan. 10, 1852. 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

47. Peach-Leaf Water. By Messrs. Fellenberg and Konig. — The authors 
distilled, in 1847 and 1848, peach-leaves with water, and the difference in the 
proportions of prussic acid in these two sorts of water was very considerable. 
The leaves which yielded the smaller proportion of prussic acid were those of 
the year 1848, when the tree had an abundance of fruit, whilst in the year 1847 
it had only one fruit. Mr. Konig, in Bern, found in 1000 parts of peach-leaf 
water, prepared by himself, 1.407 of prussic acid. That prepared by Fellenberg, 
in 1848, contained in 1000 parts. 0.437 parts. — Pharmaceutical Journal, Dec. 
1851, from Central Blatt. .' T. R. B. 



1852.] 



Medical Jurisprudence and Toxicology. 



269 



48. Detection of Mercury in the Body of a Person dying of Mercurial Cachexy. 
By M. Gorup-Besanez. — The subject was a woman, who, for twenty-five years, 
was laboriously engaged in silvering looking-glasses ; but who, from the con- 
vulsive tremors that were induced, had been obliged to desist from her occupa- 
tion for a year prior to her death. 

The chemical results obtained by following the processes of Fresenius and 
Babo were as follows : The lungs and heart gave no trace of mercury, a very 
small quantity was detected in the liver, and none in the bile. A doubtful pre- 
cipitate was thrown down upon the gold plate by the brain, while the spinal 
column presented no traces. That any remains of it should be found after a 
year is remarkable ; and is confirmatory of other facts, proving how long cer- 
tain metals, e. g., antimony, may be retained in the economy. That the liver 
was the only organ in which it could then be detected, confirms the doctrine 
that metallic poisons are usually found longest in that organ. — Chem. Gaz., 
Nov. 15, 1851, from Buchner's Repertorium. T. R. B. 

49. On Poisoning by Datura, in Bombay. By Dr. Giraud. — This species of 
poisoning excites great interest in Bombay, in consequence of the frequency of 
its occurrence, and the secrecy with which the crime is perpetrated. During 
1848, there were forty-nine males and two females treated for it in the Native 
Hospital. Of this number, four only exhibited alarming symptoms, and no one 
proved fatal. The datura, indigenous to India, is probably less fatal than the 
D. stramonium, several examples of fatal poisoning by which are on record. 
The powdered seeds are employed, concealed in rice, or other grain, but the 
quantities given are unknown, so secret has the administration (usually to faci- 
litate robbery) been kept. In many cases, three stages of symptoms are ob- 
served : Primary delirium, sopor, or even coma ; and secondary delirium — a 
single stage, that of delirium only, occurring in mild cases. The primary 
delirium may be vociferous or merely garrulous, the patient usually manifesting 
excessive timidity. In both this and the soporific stage, he is constantly en- 
gaged in' picking at real or imaginary objects, and sometimes in performing 
such antics as to render laughter on the part even of friends unavoidable. 
Several of these movements seem to depend on perverted vision, which destroys 
the power of judging of the distance of objects, and which may be due to the 
widely dilated pupil, a persistent symptom. The pulse and temperature, usu- 
ally natural, undergo in some cases extremes of exaltation and depression. 
In the majority of cases, the soporose stage is absent, the delirium subsisting 
for from six to ten hours. On recovery, the person usually recollects nothing 
since the meal at which he was poisoned, so rapid are its effects. Emetics are 
given if the patient is seen early enough. Afterwards leeches are applied to 
the temples, the cold affusion to the head, while small doses of opium with 
tartar emetic are administered internally. — Brit, and For. Med.-Chirurg. Rev., 
Jan. 1851, from Trans, of Med. and Phys. Soc. of Bombay. T. R. B. 

50. Question of Pregnancy in Bodies far gone in Putrefaction. — Dr. Casper 
relates an interesting case in exemplification of a point he has frequently illus- 
trated, viz., the much longer exemption which the uterus obtains from putrefaction 
compared to other organs. A young woman was missed, and it was suspected 
that she was pregnant, and that her paramour had possibly made way with her. 
Nine months afterwards her body was found in a privy, having been macerated 
during that period in feces and urine. The horrible condition it was reduced 
to, may be imagined, and was such as to overcome the most hardened habitues 
of the dissecting-room. Many of the soft parts had fallen from the bones, and 
the rest were converted into a gray fatty matter, so that anything like a post- 
mortem examination became impossible. Still, as from old experience, Dr. 
Casper expressed his conviction that, if the woman had been pregnant when 
she died, the foetal bones would be recognizable, the abdomen was opened. Its 
muscles were converted into adipocire, and the various parts of the abdominal 
canal were not distinguishable from each other ; still, there was the uterus of a 
light red colour, firm in texture, and of the normal size and form of a non- 
pregnant woman. The cavity also was normal in appearance, and quite empty. 

No. XL VII.— July, 1852. 18 



270 



Progress of the Medical Sciences. 



[July, 



Thus, if the investigation could not ascertain the cause of death, it at least 
proved she was not. pregnant, and removed the aspersion cast upon an innocent 
person. — Quoted from Casper, in Med. Times, Nov. 1851. T. R. B. 

51. Eaters of Arsenic. — A letter from Vienna, dated Oct. 28, 1851, to the 
Gazette des Tribunaux, has the following details : — 

A few days ago, the assizes opened at Colli, in Styria. Among the cases, 
was that of a charge of poisoning. The victim was an old soldier, named 
Wurtzel, who died suddenly in the month of May last, and in whose stomach, 
on examination, arsenic was found. The Vienna newspapers, in giving an 
account of the case, report that the court, in submitting it to the jury, presented 
the following question : "Was the deceased an arsenic eater ?" To which the 
jury replied, " Yes, he probably was." 

This question and answer have excited great interest, and it was at one time 
supposed that the report was altogether suppositious or erroneous. But the 
following explanation is now given on good authority : In the provinces of 
Lower Austria and of Styria, bordering on Hungary, it is quite common with 
men, to chew particles of arsenic, mixed with their bread, very much like the 
Chinese chew opium. The absorption of the small quantity thus used, induces 
a fresh and clear complexion, and, to a certain extent, brightens the intellectual 
faculties ; but with those who make a habit of thus eating it, there follow, before 
long, debility and a premature death. Females do not at all indulge in it, and 
the few men thus distinguished, are known by the name of eaters of poison. — 
Journal des Connaissances Med.-Chirurg., Dec. 16, 1851. T. R. B. 

52. Elimination of Certain Poisons. Comparison of the Pesults. Action of 
Ethylamine and of Amylamine on the Animal Economy. By M. Orfila (said to 
be the nephew of the distinguished toxicologist). — When a poison has been 
absorbed and carried into the different tissues of the living body, does it remain 
for an indefinite time in these tissues, or is it expelled ? If the latter, how long 
a time is required? And, lastly, in what manner is it expelled ? 

It requires a long time to perform conclusive experiments, which shall reply 
to these questions. Thus, at the end of eighteen months, I can only submit the 
results obtained with four poisons — corrosive sublimate, acetate of lead, sul- 
phate of copper, and nitrate of silver. It would seem from these, that when 
corrosive sublimate has been administered for some time, it will generally dis- 
appear from the organs in eight or ten days (I found it but once on the eighteenth 
day) ; that lead and copper are found in the liver, the intestinal coverings, and 
in the bone, eight months after we have ceased giving it by the stomach ; and 
that nitrate of silver may possibly be proved to be present in the liver in some 
instances, at the end of six months, but is not found in any organ seven 
months after it has been administered. 

During these researches, I found lead, copper, and mercury to pass off by the 
urine; but while the first two appeared only two days in that secretion, after 
giving a saturnine or cupreous compound; the last one, mercury, manifested 
itself for eight days, after taking a mercurial preparation. I have never been 
able to detect silver in the urine of those who had taken the nitrate. 

The importance of attention to this subject may be illustrated by some 
examples. 

An individual had undergone a course of treatment with corrosive sublimate, 
and died four months after ceasing the course. He is poisoned with a mer- 
curial preparation. On analysis, mercury is found in his organs. Now, ac- 
cording to my experience, this mercury was not derived from the preparations 
taken four months before his death, since, according to observation, it never 
remains longer than eighteen days. 

When a man survives fifteen days after being poisoned with corrosive subli- 
mate, it is quite probable that the experts will find no trace of mercury. 
They will, however, commit a gross error, if they conclude from this that there 
has been no poisoning. 

Again, a manufacturer of lead died two months after he had altogether given 
up his occupation. On examination, lead was found in his organs. Was this 



1852.] 



Medical Jurisprudence and Toxicology. 



271 



the result of poisoning, or of his previous occupation? We can only solve this 
problem, by weighing carefully the history of the symptoms from their com- 
mencement to the fatal termination, and compare these with the results of the 
chemical inquiry. 

Comparison of the processes required in these investigations. — There are three, 
which are employed for the detection of lead and copper, and they scarcely 
differ from each other, except as to the agent used for the carbonization of the 
animal matter. These agents are : 1, nitric acid ; 2, nitric acid mixed with 
one-fifth of the chlorate of potash ; and, 3, sulphuric acid. I deduce from my 
experience, that carbonization by nitric acid is superior to that by either of the 
others, but the second is still superior to the third. 

For mercury, the best process is to carbonize with sulphuric acid. M. La- 
naux has proposed to destroy the animal matter with a current of chlorine, but 
I have not found this to answer as well as the others. 

Action of Ethylamine and Amylamine. — Being struck with the analogy that 
exists between the physical and chemical properties of these bases and those of 
ammonia, I was desirous of ascertaining whether these effects on the animal 
economy were also analogous. And on dogs, it was found that the action of 
these alkalies and of ammonia, perfectly resembled each other, in the symptoms 
of poisoning, and the lesions of the tissues. And this analogy remained con- 
stant, whether they were introduced into the stomach, or whether the animals 
were made to breathe an atmosphere charged with them. — Comptes Rendus, 
Jan. 15, 1852. T. R. B. 

53. Dyson v. Dyson. — This was a case heard in the Vice-Chancellor's Court, 
before Sir G. Turner, so far resembling the notorious Gardner Peerage case, 
that its main point depended on the duration of the period of utero-gestation ; 
it being alleged that the plaintiff, an infant, though born in wedlock, was not 
the child of Dyson, the defendant. It was proved, in the cause, that the alleged 
father left his wife in the Island of Madeira, in February, 1849, that she re- 
turned'to England, in the August following, and that the plaintiff was born on 
the 8th of January, 1850, being a period of 336 days (or 11 months 6 days, 
each month comprising 30 days), after the father had left Madeira. Mr. Hare, 
for the plaintiff, read the evidence of several medical witnesses of eminence, 
who deposed to the possibility of the period of gestation being protracted to a 
period of 330, or even of 336 days ; and referred to a case in which a foreign 
court had decreed a child born 336 days after access, to be entitled to the suc- 
cession. The vice-chancellor referred to the Gardner Peerage case, in which a 
period of non-access considerably shorter than the period in question had been 
held by the House of Lords, to be decisive against the legitimacy of the child, 
and said that he could not make a decree in favour of the plaintiff on the pre- 
sent evidence ; but the plaintiff was entitled to an issue ; which, however, his 
counsel declined, and the bill was dismissed. It appeared that the possession 
of a share of a large landed and personal estate was involved in the affair. — 
Med. Times and Gaz., Feb. 28, 1852. T. R. B. 

54. Suicide or Homicide. — A case occurred at the University College Hospital, 
under the care of Mr. Erichsen, of a man who attempted to destroy himself by 
cutting his throat. The patient is progressing favourably, but there is a pecu- 
liarity in the case which might have been of great importance had he succeeded 
in killing himself. It appeared that he seized the cutting instrument with 
both hands, and inflicted a wound on the right side of the neck. Now it is 
generally held, that unless a man is left handed, he cannot do this ; and had the 
man died under doubtful circumstances, it might have been argued, that the 
wound was inflicted by a second person, and suspicions might have been raised 
against perfectly innocent persons. Mr. Erichsen stated that a case of a similar 
nature was received into the hospital some years since. These facts are cer- 
tainly of great value, and should be carefully noted. — Lancet, Jan. 31, 1852. 

T. R. B. 

55. New Test of Mercury. — If a strong solution of iodide of potassium be 
added to a minute portion of any of the salts of mercury, placed on a clean, 



272 



Progress of the Medical Sciences. 



bright plate of copper, the mercury is immediately deposited in the metallic 
state, appearing as a silvery stain on the copper, which cannot be mistaken, as 
no other metal is deposited by the same means. 

By this method, corrosive sublimate may be detected in a drop of solution, 
unaffected either by caustic potash, or iodide of potassium. In a mixture of 
calomel and sugar, in the proportion of one grain to two hundred, a distinct 
metallic stain will be obtained with one grain, which contains l-200th of a 
grain of calomel ; in like manner, l-400th of a grain of peroxide of mercury 
may be detected, although the mixture with sugar is not in the least coloured 
by it.' ' ■ ■ ' ■ y \vC't*}.*$ >rH'^il»V^mm 

With the preparations of mercury in the undiluted state, this process acts 
with remarkable accuracy; the smallest possible quantity of calomel or peroxide 
of mercury, such as would almost require a magnifying lens to perceive, placed 
on copper treated with iodide of potassium, will give a distinct metallic 
stain. 

The advantages of this test may be briefly stated as follows : 1. It is a deli- 
cate one, only inferior to chloride of zinc, and the galvanic test of zinc and gold. 
2. It is easy of application. 3. It requires a very small portion of the substance 
to be examined — a matter of no small import. 4. Acting on insoluble as well 
as on the soluble salts, it obviates the intermediate process of solution. 5. 
when it acts, its indications are decisive. 

As to its disadvantages, the only one that seems tenable, is that, though it acts 
on minute portions, still, that must be in a concentrated condition. For in- 
stance, though we may detect the l-1000th of a grain of corrosive sublimate in 
a drop of water, we cannot detect it in a drachm ; but this may, of course, be 
remedied by evaporation. 

As to the theory, most probably, the iodide forms a soluble and easily decom- 
posed salt, with the various salts of mercury ; that is, an iodide soluble in ex- 
cess of the iodide of potassium. 

The foregoing is the substance of a paper read by Mr. Arthur Morgan, City 
of Dublin Hospital, at the first meeting of the Student's Medico-Chirurgical 
Society, Dec. 12, 1851. — Pharm. Journ., Feb. 1852, from Dub. Med. Press. 

T. R. B. 

56. Morphine and Chloroform. — The following are extracts from a London 
newspaper, The Atlas, April 10, 1852 ; and are, therefore, not as good authority 
as a medical journal, but still they may be correct in all respects : — 

" A physician in Prague has just died a real ' martyr to science/ He had 
been in the habit of taking strong doses of poison, after swallowing an antidote, 
in order to note their effects. On the 23d ult., he took so large a quantity of 
morphine, that all the efforts of some medical friends present at the exhibition 
could not save him." 

"In resuscitating from an overdose of chloroform, galvanism is the only 
chance. Keep up a current of electricity through the fifth nerve, medulla ob- 
longata, phrenic nerves, and diaphragm, as long as respiratory movements can 
be produced, and let the patient have plenty of fresh air or oxygen gas, and the 
case must do well, for the blood must remain fluid for a long time, and circu- 
lation will go on as long as respiration continues to go on artificially. The 
blood and the air-cells throw off their load, and in proportion as the pneumo- 
gastric, medulla oblongata, and motor nerves, slowly resume their functions, so 
respiration begins to assume a less artificial character ; at length, the cerebrum 
aids us, and respiratory movements, both voluntary and involuntary, keep up 
the functions of life unaided." — Dr. Herepath. T. R. B. 

57. Smothering voluntarily produced. — The following case, quoted from Henke's 
Zeitschrift, at once reminds us of the melancholy story of " Genevieve," in 
Samuel Rogers's Italy, though deprived of the romantic interest thrown around 
that by the skill of the poet. 

The narrative is given by Dr. Roth, and the question submitted to the re- 
porters was, as to whether the death of H , a servant-maid, had been the 

result of suicide, or of homicide. 



1852.] 



Medical Jurisprudence and Toxicology. 



273 



The deceased was well formed, about the middle height, and about twenty- 
five years of age. She had been seen to retire to her sleeping-room, at 9 o'clock 
one evening, in her usual state of health and spirits. The apartment was only 
separated by a partition from the one in which her master and mistress slept, 
and was over a room occupied by others of the household. At half past 5 o'clock 
on the following morning, the master knocked against the partition to awaken 
H., but receiving no answer, supposed she had risen and gone out to her work. 
On getting up, however, he found all the doors and windows of the house 
closed, when he went into the servants' room, but did not find her there. On 
the bed was an axe of a peculiar shape, employed in that part of the country 
for clipping off branches from the trees, and which used to hang behind the 
door. The blade of the axe rested against the back of the bed, and the handle 
on the bed. Beside it lay the best bonnet, which she used to keep in her chest. 
The bed appeared to have been slept on. After searching the well, lest she 
had drowned herself, H.'s father was sent for, from a neighbouring village. 
On his arrival, he suggested that the chest should be opened to learn in what 
trim his daughter had left the place. Finding the chest locked, and the key 
missing, a blacksmith was got to force it open, when the body of the servant 
was discovered in the chest, lying in a prone position, on the left side, with its 
knees drawn up, the upper extremities flexed, and the missing key grasped in 
the woman's right hand. The chest was about four and a half feet in length, 
and of proportionate depth. It locked itself on the fall of the lid, and could 
not have been opened from the inside. The corpse was nearly dressed, and the 
vest (camisol) was put on with its inner side out. On the following day, the 
body, which had been removed and laid on a bed, was viewed by the reporter. 
The cuticle was abraded and reddish-brown at seven or eight points, about the 
centre and upper part of the forehead. The largest of these abrasions corre- 
sponded with the thick part of the axe, and underneath them, the integuments 
were slightly swollen and bluish. The face and upper part of the chest were 
mottled with cadaveric lividities, the ears were blue, the eyelids closed, the 
conjunctivae injected, and the pupils dilated. There was bloody froth about 
the lips and nostrils, partly dry, partly fresh, and giving this part of the face a 
blood-stained appearance. Bloody froth was issuing at the time from the right 
nostril. The mouth readily opened, showing the tongue in its natural position. 
The key was still grasped in the right hand. With the exception of the abra- 
sions on the forehead, no traces of injury were detected on the body. The 
clothes were entire. 

From the foregoing circumstances, the reporter was of opinion that the 
deceased had employed the axe which hung in her room, to kill herself, in the 
way she had seen others slaughter oxen, and that, failing in the attempt, and, 
perhaps, ashamed of the injuries on her forehead, she had then shut her- 
self up in her chest, and perished by smothering. This conclusion satisfied 
the law authorities so completely, that they decided that there was no necessity 
for making a post-mortem inspection. — London Med. Gaz., Sept. 5, 1851. 

T. R. B. 

58. Case of Poisoning by Atropin. By Dr. James Andrew, M. 1)., of the 
Royal Infirmary, Edinburgh. — Sarah Jackson, aged twenty-one, was a patient 
of the Infirmary, and during her residence there, in consequence of a dimness 
of vision in the right eye, succeeding iritis, was directed to apply a drop of a 
solution containing atropin, every day, to the affected organ. She was doing 
so well, that she would probably have been discharged on the next day, when, 
on rising from bed, she asked another patient to hand her her medicine (which 
was a draught of bitters, that she took every morning). The solution of atropin 
was by mistake handed to her. This originally contained two grains of atro- 
pin, one drachm of diluted acetic acid, and one and a half ounces of water. 
On measuring what remained after the accident, it was found to be seven 
drachms, and as the fourth of a drachm had been used as a collyrium, it fol- 
lows that she must have swallowed between five and six drachms of the solu- 
tion, or about two-thirds of a grain of atropin. Immediately on swallowing, 
she became sensible of a burning feeling in her throat, and said to those around 



274 



Progress of the Medical Sciences. 



her that a mistake had "been made, but that she supposed what was good ex- 
ternally, could not be very injurious when taken inwardly. But in a few 
moments her eyesight failed her, and she had a desire to move about, but was 
deeply oppressed, and her voice failed. The nurse, aware of the accident, gave 
her large quantities of milk, which soon induced vomiting. In fifteen minutes 
after the accident, the pupils were seen to be widely dilated, the eyeballs con- 
gested and prominent, with loss of sight. The muscles of the mouth and eye- 
lids frequently twitched, and her pulse was 130. She was very restless, and 
on attempting to get out of bed, staggered, and would have fallen, if she had 
not been prevented. She complained of a burning heat in her throat and sto- 
mach. The vomiting was kept up, by giving thirty grains of sulphate of zinc. 
In two hours, and when it had ceased, she became rather drowsy. Two drops 
of croton oil were then administered, cold cloths applied to the head, and bot- 
tles of hot water to the feet. As the drowsiness still seemed to increase, forty 
minims of the aromatic spirit of ammonia were ordered, to be repeated every 
half hour, if necessary; and the house physician was instructed to apply the 
galvanic battery should there be greater amount of narcotism. This was, 
however, not required ; but an additional quantity of croton oil was necessary, 
in order to move the bowels. The next day, she was at first restless, then vio- 
lently agitated, and at last so furious that it required several persons to hold 
her. The straight-jacket was used, but she talked incessantly, tossed about 
in bed ; with a quick pulse, eyes bloodshot, pupils dilated, and face highly 
flushed. She continued to hawk and spit, and her bowels were moved twelve 
times during the afternoon and evening. Towards night she became quiet, 
apparently exhausted by the great efforts she had been making. On the fol- 
lowing morning, there was still a great degree of nervous tremor of the eye- 
lids and hands; and when spoken to, she started, as if alarmed. But in other 
respects she was improved: and this continued with some variableness, until 
the 4th of November, when she was dismissed cured. She took the poison on 
the 21st of October. During what may be styled the period of convalescence 
and recovery, the prevailing unfavourable symptoms were restlessness, dilata- 
tion of